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JUDITH T.TERRY y< Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
we �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :.O ��� Fax(516) 765-1823
MARRIAGE OFFICER �f� � �� Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER JL *��.0
FREEDOM OF INFORMATION OFFICER .�.��,.••'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3490-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DAVIES, ANNE
Mailing Address 1 P. O. BOX 2114
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 435 ROBINSON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-734-7396
Tax Map No. section 34.00 block 5 lot 10.000
Cross Street CHAMPLIN PLACE
Issue Date: 7/25/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •cvFFO(/i- '- C�
Town of Southold �� CQG'�� Application No.L9i°
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential x
P. O. Box 1179 v' $25.00 - Non-Residential
Southold, New York 11971 O- ol ••`
`�7 °.�.. N.- •
Telephone � )\• •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
•
DATE 7/22 , 1996
OWNER NAME: Anne Davies
OWNER MAILING ADDRESS: PO Box 2114
Greenport , NY 11944
OWNER PROPERTY ADDRESS: 435 Robinson Rd.
GrPQnport , NY
OWNER TELEPHONE NUMBER: 516 734-7396
TAX MAP NO. : Section 4-,e(D Block Oc i U(_D Lot cj� r)
CROSS STREET: Champlin Place
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing x
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.)
GA's
—Signat .►''.f Applican
RECEIVED BY:
Town Clerk's Office
DATE:
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July 22 , 1996
Southold Town Clerk
Town of Southold
53095 Main Road
PO Box 1179
Southold, NY 11971
Dear Ms. Terry:
As I do not have a copy of the property survey, I 've made
a map to show where the cesspool is located with the hope
that this will suffice for the information needed. Also
enclosed is a check for the $10 fee to cover the cost of
the permit for the dumping of cesspool waste. The waste
was pumped out by Morris Cesspool Service some months back.
Sincerely,
ac•- el--%/%C.s .‹.„r.D_Dskc. ,
Anne Davi s Kaloski
adk/s
Enc.