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JUDITH T. TERRY .4 Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ® .� Fax (516) 765-1823
r �® t 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. 2006-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEWAR, CAROLYN
Mailing Address 1 4420 OAKLAWN AVENUE EXTENSION
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4420 OAKLAWN AVENUE EXTENSION
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2085
Tax Map No. section 70.00 block 9 lot 46.000
Cross Street PINE NECK ROAD
Date Of Last Pump Out 0/00/86
Issue Date:. 11/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c,VFFO(,r '=
Town of Southold t.� e,-_ Application No. ,2 06 6
Judith T. Terry, Town Clerk �� �'' C
Town Hall, 53095 Main Road u $10.00 - Residential
p. O. Box 1179 u' . $25.00 - Non-Residential
Southold, New York 11971 T•�`
Telephone j .kg
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE jib Z f -2—
OWNER NAME: 04 eo xyfo 1,61/_)/9
OWNER MAILING ADDRESS: 471L Q n 4.9/CL 9-( 'M ,41/ EX 7--
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: /6
TAX MAP NO. : Section '7 0 Block Lot
CROSS STREET: �liy� �- lC/i
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
014—e1=-4
SX�ature o pplicant
RECEIVED BY:
own Clerk's Office
DATE:
5-6 t17
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