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JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS U' .,, Southold, New York 11971
'` t Fax (516) 765-1823
MARRIAGE OFFICER ® ®� •
.9 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. 3000-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DOLAN, KEITH T.
Mailing Address 1 P. O. BOX 319
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 VANSTON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5195
Tax Map No. section 111 .00 block 6 lot 7.000
Cross Street OLD COVE ROAD
Date Of Last Pump Out 0/00./00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK • FOUr
Town of Southold Application No. 3oOO
Judith T. Terry, Town Clerk �
Town Hall, 53095 Main Road rC i<„ -4. $10.00 - Residential
P. O. Box 1179 rt 5 ?( *
,*� $25.00 - Non-Residential
Southold, New York 11971 :.Telephone
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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 / /73
OWNER NAME: ,I' iii 7 7- 0L.A//
OWNER MAILING ADDRESS: f O, ogeY)C
evcogvrr NY, /1935
OWNER PROPERTY ADDRESS: -' - - ---4/jgA/97 7f /O
Cil MIC C,/, N, ,k /4'35 TELEPHONE NUMBER: ( ..-)-760 _.0 S/9
TAX MAP NO. : Section / / / Block 6 Lot 7
CROSS STREET: L0- de-W
TYPE OF SYSTEM: Septic Tank - -New Existing - -
Cesspool ' New Existing
Residential i 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.)
Signature of Applicant
RECEIVED BY: ('/� --
To n Clerk's Office
DATE: / 3 73 - -- -- - -
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