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JUDITH T. TERRY A' Town Hall, 53095 Main Road
TOWN CLERK ` ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS l&P .� Southold, New York 11971
MARRIAGE OFFICER �® C) ® ''�. Fax (516) 765-1823
em) �' 4' 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. 3062-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOSS, FRANCIS H.
Mailing Address 1 P. O. BOX 1205
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2145 HAYWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5807
Tax Map No. section 111 .00 block 7 lot 3.000
Cross Street OLD MENHADEN ROAD
Date Of Last Pump Out 0/00/83
Issue Date: 7/13/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFDUr�'-
Town of Southold ;. _ Oa% Application No.� O G
Judith T. Terry, Town Clerk "w fitti y
$10.00 - Residential /�
Town Hall, 53095 Main Road
�G !
p. O. Box 1179 u-3 tecr13,‘,. �= r �*� $25.00 - Non-Residential
Southold, New York 11971bi - 0 ��`
Telephone 0.( �� '/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /1 ' /;? /C
OWNER NAME: F/MA/C/t5' / ° B Esc del(}/
OWNER MAILING ADDRESS: /60 /02,6)....6—
OWNER PROPERTY ADDRESS: 2/f-,LS- //4ye /A-]''ti /°,' /zip
OWNER TELEPHONE NUMBER: �/ --7-;7 -.5-2P07
TAX MAP NO. : Section Block t� Lot 37Co
CROSS STREET: O/C` /Y u f//�D i ti/ R D
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: O ,�4rer,i / 9/ 'c7/°',S"
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.)
G in°��
Signatiure o Applicant
RECEIVED BY: `-E''4_ s - - - -
• .wrf Cler Office -
DATE:
JUL 13 1991 -
Too CIO Southard
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