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JUDITH T. TERRY ; Z < Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER1% Fax (516) 765-1823
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`®1 ��® �' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1762-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BEASLEY, DWIGHT
Mailing Address 1 575 NORTH BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 575 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5308
Tax Map No. section 78.00 block 8 lot 16.005
Cross Street CEDAR DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 9/20/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COW
Town 76
Town of Southold �� C's • Application No.
Judith T. Terry, Town Clerk }� �' $10.00 - Residential
Town Hall, 53095 Main Road 8 VC
P. O. Box 1179 u' : ' 1. ��`' $25.00 - Non-Residential
Southold, New York 11971 v.® ~,
Telephone '51°(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT "
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ •
DATE
OWNER NAME: A51 ik� /J0d0,5--
OWNER MAILING ADDRESS: e,„/6-.9 �yry�,�� /f� y f /�ta1 eXy it)OWNER PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER: 7 $3
TAX MAP NO. : Section ? if Block Lot g', �J
CROSS STREET: e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �� New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: s'sO
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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w-`•nat " o ' pplic.
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RECEIVED BY:
Town Clerk's Office
DATE:
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