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JUDITH T. TERRY
Town Hall, 53095 Main Road
kcalt4 „ �r P.O. Box 1179
REGISTRAR OF V VITAL CLERK STATISTICS �; WT - r?
4_ ,n � r Southold, New York 11971
MARRIAGE OFFICERS .6 `~ � Fax (516) 765-1823
=:®�i 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. 1831-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DELAND, PAUL K. AND THELMA W.
Mailing Address 1 5 ARLINGTON COURT
Mailing Address 2
City St Zip CALDWELL NJ 07006-0000
Property Address 1 186 WILLOW TERRACE LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 201-226-4039
Tax Map No. section 26.00 block 2 lot 4.001
Cross Street KING STREET
Date Of Last Pump Out 0/00/00
Issue Date: 1/14/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
V. -
OFFI°CE OF THE TOWN CLERK ic31.FO(,r��=
Town of Southold CQG•; Application No.
Judith T. Terry, Town Clerk +,
Town Hall, 53095 Main Road -� $10.00 - Residential
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p. O.- Box 1179 cn14-1. $25.00 - Non-Residential
Southold, New York 11971 OO 4"/�`
Telephone = .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
' for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL -
Operation Permit No.
Fee $ fQ,
DATE JGC. •3:a� lqq d
•
OWNER NAME: FAva K. ra -ELr1 ALP 1.1-0
OWNER MAILING ADDRESS: 5' couR
cA.t-'aDwe LL 1.f. J 07006
OWNER PROPERTY ADDRESS: _ ; ( 6 W 1.-0w �G=�Rai4 L-P JE
c9 t(SA./ ri' • IMS-7
OWNER TELEPHONE NUMBER: t-{ 03 q
TAX MAP NO. : Section ; 2 Block `}- Lot
CROSS STREET:
Existing
OF SYSTEM: Septic Tank -• �, New
Cesspool New Existing ✓
Residential ° Non-Residential
DATE OF PREVIOUS PUMP-OUT: JUL' I7 (991
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.)
tgnature of Applican
RECEIVED BY:
Town Clerk's Office .
DATE:
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