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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK
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P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER44 � Fax (516) 765-1823
�®" 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. 3051-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DOBSON, PETER AND LAUREEN
Mailing Address 1 425 LONG CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 425 LONG CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3711
Tax Map No. section 55.00 block 3 lot 24.000
Cross Street TUTH I LL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFF-16'E OF THE TOWN CLERK
Town of Southold OC��FF�(�'
CQ Application No-
Judith T. 'Terry, Town. Terr •
Town Hall, 53095 Main Road � ; ; - ` $10.00 - Residential
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P. O. Box 1179 cr3 aT► .` $25.00 - Non-Residential
Southold, New York 11971
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Telephone ,�o 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for '
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 64 0/5.
OWNER NAME: 124;777 4 id . loos Uri. A'dVO J 't1- 'S /905soc,
OWNER MAILING ADDRESS: /2 ) la ',f/ (/-
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OWNER PROPERTY ADDRESS: ty 2,5"- d rf& C41(=bill
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OWNER TELEPHONE NUMBER: 5/6 76 (' 3 7 / /
TAX MAP NO. : Section Block 3 Lot 4R V
CROSS STREET: 30o / 1mr e. T(ir/1/L(. ,rd
• TYPE;OF SYSTEM: Septic Tank New Existing
Cesspool New Existing i/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /Mt f?73
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 arid closest road.)
ignature o Applicant
•
RECEIVED BY:
Town Clerk's Office •
DATE: '
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