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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK c r P.O. Box 1179
REGISTRAR OF VITAL STATISTICS . ,�` Southold, New York 11971
MARRIAGE OFFICER " Fax oO Fax (516) 765-1823
�® �! Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1969-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BEST, THOMAS AND SUSAN
Mailing Address 1 10220 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 10220 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8185
Tax Map No. section 122.00 block 2 lot 10.000
Cross Street FACTORY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/17/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFi'u`� OF THE TOWN CLERK �,�FFO'.'�' '
Town of Southold �� �C'0 - Application No. r 5
per. � ��- � G
Judith T. Terry, Town Clerk ria; f*.
Town Hall, 53095 Main Road ~ ' '" , , . 1 $10:00 •- Residential
p. 0. Box 1179 cn Vi. Z ' $25.00 - Non-Residential
Southold, New York 11971 O t,• . Ot' .��`
Telephone O/ `j► '°
Pr(516) 765-1801
TOWN OF SOUTHOLD ,
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. i.
. Fee $1 O•esb 1\
`_ DATE ja. Iy Ig., !gel./
OWNER NAME: 1 kph.,,l/ Su.5c.n
OWNER MAILING ADDRESS: l6Z2n 3o .'.ic1 aye .
ill c....a..tg,,..ciz. 1V Y
OWNER PROPERTY ADDRESS: 3.ee f„,:..4 ‘,.,- 0_,„1.C4lre.5s --
OWNER TELEPHONE NUMBER: ,I-5' e - g I s5
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i 'a
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TAX MAP NO. : Section -&& Block �, Lot / 0 e ( C
t
CROSS STREET: F4or_i 0 ve
:J,rot• ,- ^3
TYPE--OF SYSTEM: Septic-Tank - - New Existing
Cesspool ., New Existing - / Y.
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7
„LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signatur f Applicant
RECEIVED.• BY_: Ct
-- - -- - - -- - .. _ - .- .,. ..
Clerk' Office w t .
RE
DATE: . _
,_ - - .
SEPI 71992 _
Town Clerk SolltWio1
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ARE No7- GUARANTEEr .. b/ S T /000 tSEC • /22 BLI.:_•.. z Loy$ /04e. //
;MEASUREMENTS IN U.S. STANDARD
THE DIMENSIONS SHOWN HEREON, FROM THE STRUCTURES TO THE PROPERTY LINE ARE FOR A SPECIFIC PURPOSE ONLY.THEY
ARE NOT INTENDED TO BE USED FOR THE ERECTION OF FENCES,STRUCTURES OR ANY OTHER IMPROVEMENT.
•
' GUARANTEES
Y TO
THE PERSON FOR WHOM THE SURVEY SN LPREPARED,L RUN L AND
UNAUTHORIZED ALTERATIONS OR ADDI COPIES OF THIS SURVEY MAP NOT ON IIS BEHALF TO THE TITLE COMPANY GOVERPMEN-
TO THIS IS A VIOLATION BEARING THE LAND SURVEYOR'S TAL AGENCY AND LENDING INSTITUTION LISTED HEREON,
TIONS SECTION THIS SURVEY VISION2 OFOLA THE INKED 'SEAL OR EMBOSSED, SEAL AND TO THE ASSIGNEES OF THE LENDING
NEW YORK EDUCATION LAW. SHALL NOT BE CONSIDERED TO BE A INSTITUTION.
VALID TRUE COPY. - GUARANTEES ARE NOT TRANSFERABLE TO ADDITIONAL
INSTITUTIONS OR SUBSEQUENT OWNERS.
KULHANEK ,& PLAN SECTION BLOCK DATE ;
LAND �,�F1lIE�'OR , P.C. I
� _...--- -----.7._:- GUARANTEED TO 7. 30- 9 I
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LONG ISLAND OFFICE WESTCHESlER OFFICE COUNTY
P.0 BO;` 487 P.3 BOX 178
LONG BEACH, N.Y. 11561 PCUND`17iJCE, N Y 105/3 - JOB NO.
800-541-5124
FAX(516)431-9-161 FAX(014)7640306
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