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Town Hall, 53095 Main Road
``cam® `� P.O. Box 1179
EZnSouthold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)7654801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1039-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DOHM, HELEN
Mailing Address 1 330 SOUND AVENUE
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 330 SOUND AVENUE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-5420
Tax Map No. section 67.00 block 1 lot 6.000
Cross Street MILL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •51F0(,r��- q
Town of Southold �� #y ; CQ ' Application_ No. /d3
Judith T. Terry, Town Clerk Residential
Town Hall, 53095 Main Road L'A
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P. O. Box 1179 � � , �: ' • Non-Residential
Southold, New York 11971O0 �0�
Telephone _ ( 0'
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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 $ /6 —
DATE
/
OWNER NAME: ►4 i
OWNER MAILING ADDRESS:33 0
OWNER PROPERTY ADDRESS: J 3b
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OWNER TELEPHONE NUMBER: 76' ji , LQ
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool , 11411111Existing
Residential tp..41 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.)
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Signature of /applicant
RECEIVED BY:
Town 'Clerk's fice
• DATE: � � 'zad " �
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