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ELIZABETH A.NEVILLE '4° 4 •;
SO
OFFICE OF^ THE TOWN CLERK �FFOu `
—Town of Southold Application No.
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 v' n z'
$25.00 - Non-Residential
Southold, New York 11971 O` *.$
Telephone = ( ift yi '
6.9
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
_ -__ _ for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ t,Q',D0
DATE 1 /-7 /9
OWNER NAME: L5 (Y1 , >If
OWNER MAILING ADDRESS: I ( G S, SA-64-Q._ Rs-
r�' r c L c Mat)da n1`( t o,ci o
OWNER PROPERTY ADDRESS:- 'aq_Q (SUn rl Cp lr1 Q - .
ki Y‘
n
OWNER TELEPHONE NUMBER: (9( y) ,/ �O -- 1191 4,
TAX, MAP NO. : Section I I-1 Block p Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank ✓ New Existing ✓
Cesspool New Existing
Residential >/ Non-Residential
•
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.)
ji)g,
• ignature of Applicant
-
,,� RECEIVED BY:
Town Clerk's__O-ffice__. _ -
DATE: _
TOWN OF SOUTHOLD
,��05�FFD(,�Co�c ,
SCAVENGER. TE REPORT �vo![ 6o�,,,',
Ticket No. 1 /�
_
Name of Haul � �' ,� ;, ,�� � ;'�� ,--: � , 1
Permit No. • _
....................
ill Loads@;.-.21,i: 7G
Truck Ca
. Gallons
pacify..,,,,,, ❑ Half Load(a� Gallon
�•• 0 $..''1...:...... ... Paid ...............
LOCATION:, 12)<:lit ��C4,/y)•� G7),,,;r�; (dote)
allons-
ew YRepeat (Validation of Payment) /
.
Name of Owner r
'Street ...... .........../.�.. . ,
Hamlet'...: •G/4' 1.... ., ....4-:;, .rig .. ....--...................
ev,
.:. Tax
- Telephone No.,2a,V
Cross Street� 7..... .. ..Keiik„be.,,.4.......44,.../.7 •
............................. .. . . ..
DIAGRAM (Locate buildings and cesspool/septic :ystem and approximate
l ,�, and system;gi - northOw a distance inrfeet
if,e,
.7 ii . ---/(4,75.74 r
"e'-.11,&
";;-,: f., , . _.2r.. c.4(z ,t,ir_v,_t.:,c...ia
aff .
/41 —
I
hereby certify that the above originated within the Town of Southold/Town of Shelter '
at the above location,and to the best of my knowledge contains no chemicals, hazardous, or
toxic'wastes.. False statements made herein are punishable
Island '
Section 210-45 of the Penal Law of the State of New York, nnd may a ultain m pursuant and to
impoundment of the vehicle I a�- .,ivinmy arrest the
.Name Of Driver' / 1 j
Signature of Driver.,
Received by - r � " � •••••• ••••••••.•�:. .:;�.'/
Date ......... •. .......
.... .... ...... ............. Time ...1.62c.
,�1.-.7:.,.-2 .'.....J j.(-.7::-..,•-• . ............