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JUDITH T. TERRY ; O Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ‘104.4,
( 'I � Southold, New York 11971
MARRIAGE OFFICER Fax y Fax (516) 765-1823
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(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. 2052-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DORMAN, MARIE A.
Mailing Address 1 469 SALEN DRIVE -
Mailing Address 2
City St Zip PITTSBURGH PA 15243-0000
Property Address 1 1980 NORTH OAKWOOD ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4394
Tax Map No. section 127.00 block 6 lot 6.000
Cross Street PECONIC BAY BLVD.
Date Of Last Pump Out 0/00/60
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .0��FO 4,
Town of Southold '%c -•. �CQ Application No. �
Judith T. Terry, Town Clerk ' $10.00 - Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 Ln `"=§` tri ; $25.00 - Non-Residential
Southold, New York 11971Nc-
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Telephone ,0o9= 1 �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No. •
Fee $ /O, Oo
DATE /Eni&/i4 y /0,Iffy
OWNER NAME: /142/E 4. .ThAg19/1/
OWNER MAILING ADDRESS: Z/6 rFigEN
Pr 60eg j4 6fZ'3
OWNER PROPERTY ADDRESS: /7F oflitvav, /CD4
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s?'Ts.Sv24 H 1'2) S'6 I-6 378
OWNER TELEPHONE NUMBER: Lrtv/.g . Ls-r ) z5'8-5'39y
TAX MAP NO. : Section /2.7 Block Lot ,6
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CROSS STREET:
TYPE OF-SYSTEM: Septic Tank New Existing
Cesspool 2( New Existing X
Residential K Non-Residential
DATE OF PREVIOUS PUMP-OUT: P E 860
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.)
7Jlscutti a 09
Signature of Applicant
RECEIVED: BY: _, ,. -- ---- -
Town Clerk's Office
DATE:
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