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JUDITH T. TERRY ; `: Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS - � Southold, New York 11971
MARRIAGE OFFICER Q 0� , Fax (516) 765-1823
�1� °� Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3100-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DORS, RICHARD
Mailing Address 1 875 POND VIEW ROAD
Mailing Address 2
City St Zip RIVERHEAD NY 11901-0000
Property Address 1 43 SOUND ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-369-1906
Tax Map No. section 33.00 block 4 lot 74.000
Cross Street SUTTON PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 8/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
Ds
OFFICE OF THE TOWN CLERKFO f
Town of Southold �� - �CQG' Application No.�/OO
Judith T. Terry, Town Clerk �
•� ;:' ; C $10.00 - Residential ,k/
Town Hall, 53095 Main Road
p. O. Box 1179 v' ,ice; ,` ` $25.00 - Non-Residential
Southold, New York 11971 O t •�`
Telephone
o ; go• d
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $J
tA)
DATE
OWNER NAME: \ 0.1) art , �
OWNER MAILING ADDRESS: � e®1) V'`�
1ai � �� iA , • I - at,s -
OWNER PROPtR I Y" ADDRESS: S® U ,�
paw en 1190
OWNER TELEPHONE NUMBER: 3 (p Q — icob
TAX MAP NO. : Section 3 3 Block Lot q 1 4
CROSS STREET: 3 Jon Q �.
TYPE OF ,SYSTEM: ' Septic Tank New Existing
Cesspool New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: ( f IA fl
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.: _.
Town Clerk's Office
DATE:
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