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Town Hall, 53095 Main Road
tit .�`� P.O. Box 1179
F�'� Southold, New York 11971
JUDITH T.TERRY
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OFFICL OF THE TOWN CLERK cFa(K�,.
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Town of Southold Ay CQ Application No.
Judith T. Terry, Town Clerk
w� £� Residential
Town Hall, 53095 Main Road o 4` , •�{,
P. O. Box 1179 cry P+ .i ° hi �� Non-Residential
Southold, New York 11971 O n® ``'_" ��`
Telephone oh ..a� '��
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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 $ /D
DATE /ern
OWNER NAME:
OWNER MAILING ADDRESS: 7A--7Z- 7, �� 3
OWNER PROPERTY ADDRESS:` ` %
OWNER TELEPHONE NUMBER: cl/ —. 47" •
TAX MAP NO. : Section .4‘-- SI Block - 02 Lot l//
CROSS STREET: e/ '' Co ei:� AS:-.7(4
TYPE OF SYSTEM: Septic Tank L�'' New Existing
Cesspool J>� New Existing `—
Residential �, Non-Residential
DATE OF PREVIOUS PUMP-OUT: z""'
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.)
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ature of Applicant
RECEIVED BY:C 4(11,2, -�. C9-6c
REM VrETown Clerk's' Office
DATE: f 1:7 10 i9Rl
Town Clerk Southold
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