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OFFICE OF THE TOWN CLERKS�FFOtireo�
Town of Southold OQa
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road --
P. O. Box 1179 cn Vg_'$
Southold, New York 11971
Telephone 0,( Aid
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL-
Operation Permit No. 575 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Henry G. and Margaret DeLisle
OWNER MAILING ADDRESS: P.O, Box 324
East Marion, New York 11939
OWNER PROPERTY ADDRESS: Old Orchard Lane
East Marion, New York 11939
OWNER TELEPHONE NUMBER: 516-477-0961
TAX MAP NO. : Section 37 Block / Lot 5
CROSS STREET: Bayview Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. tgrry
Southold Town Clerk
DATE: January 14, 1988
(TOWN SEAL)
fl
OFFICE OF THE TOWN CLERK c��FFO(,�
Town of Southold _4 )),,a407� * �Q�'_� Application No.sj Cf,S
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a �� ' Residential
P. 0. Box 1179 51 '
' . �i Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ]4 / /02,/ /937r
OWNER NAME: 7,-/ /77 6., /VAR 6W.47971: _7), /5
OWNER MAILING ADDRESS: .,80,1"&—' 3c2i
Ai9 7 /v/,q,ql p,V ' ' //lc??
OWNER PROPERTY ADDRESS: a(---d / ,/Q,J� 4-4./VE
OWNER TELEPHONE NUMBER: �jC - 6 7‘
TAX MAP NO. : Section 7 Block 3 Lot ti
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V.7 Non-Residential
DATE OF PREVIOUS PUMP-OUT: /l!/4-
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.)
Sign..ture of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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GARDINER'S BAY ESTATES