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JUDITH T. TERRY ;� Town Hall, 53095 Main Road
TOWN CLERK • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS , rtrt
,ifs Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
x:tzti ,` 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. 1797-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner DBM CO.
Mailing Address 1 P. O. BOX 2130
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 1395 ORIOLE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-2223
Tax Map No. section 55.00 block 6 lot 15.031
Cross Street TUTH I LL ROAD EXT.
Date Of Last Pump Out 0/00/00
Issue Date: 11/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•OFFICE OF THE TOWN CLERK UFO
Town of Southold
�S Application No. 7 7
Judith T. Terry, Town Clerk � s _
Town Hall, 53095 Main Road "� 1 $10.00 - Residential
P. O. Box 1179 cn (, F Ori r-i
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,� „�. , $25.00 - Non-Residential
Southold, New York 119710 ,f,.Oy�/►`�
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
- - OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /2i9 7
Fee $
DATE f 1�4-9e
OWNER NAME: 1UI C-0 • •
OWNER MAILING ADDRESS: f— o • 6 0.x c>21 3 O
OWNER PROPERTY ADDRESS: 139 .-- 0 ✓. 10
OWNER TELEPHONE NUMBER: 57g., — 7 7— 2-
TAX
TAX MAP NO. : Section (5-5 Block 6 Lot /c . 3 I
CROSS STREET: %' c1 r74/z L pb • E x ! •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New r/ Existing
Residential r/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: A)I
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.)
1
,��_. rid,
Signature of Ap lica
•
RECEIVED BY: #11/
Town lerk's Office
- DATE: /0/7/9"7
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