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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O.4 Box 1179
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER O 1' 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. 1875-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DAVIS, GERTRUDE (MCLEAN)
Mailing Address 1 350 BLUE MARLIN DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 350 BLUE MARLIN DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3750
Tax Map No. section 57.00 block 1 lot 25.000
Cross Street DOLPHIN DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 4/09/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK COFair�'=
Town of Southold CQ _ Application No./
Judith T. Terry, Town Clerk � �►
Town Hall, 53095 Main Road �' '` > A..�� ) $10.00 - Residential
P. O. Box 1179tri
Z $25.00 - Non-Residential
'
Southold, New York 11971 ® , ��`�
Telephone 1 0'/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE rtril b ) i n/
I ►
OWNER NAME: &.rt ��' � ', /S el-CV
OWNER MAILING ADDRESS: Ho-jl a7ri VC_
OWNER PROPERTY ADDRESS: 350 6(k.e (ar
So ut/itO s:_oy 07/
OWNER TELEPHONE NUMBER: -g ~ '" 37
TAX MAP NO. : Section _57 Block ( Lot c
CROSS STREET:
De)1 1(1 n l Vt
TYPE OF SYSTEM: Septic Tank New Existing /\
Cesspool New Existing
Residential K Non-Re�sidential
DATE OF PREVIOUS PUMP-OUT: O( � V:)/ u-' s ti-o
00 111.14 Y)0 c4) .)6c(c —sate QS a -'
LOCATION MAP: Must be attached hereto before permit may be issued. So')') Ok
(Locate building and system; give north arrow and feeteifitLy
of distance, approximately, to building and closest road.)
7 .QAr&—C(t u ego On G/( 2)-
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
.
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