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JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK : O P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971 •
•� Fax (516) 765-1823
MARRIAGE OFFICER O 0� •
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3030-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner EBELING, BARBARA
Mailing Address 1 145 SCHOONER DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 675 CHAMPLIN PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-765-6061
Tax Map No. section 34.00 block 3 lot 30.000
Cross Street STERLING PLACE
Date Of Last Pump Out 0/00/80
Issue Date: 5/21/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0Febr �� 3
Town of Southold
Application O C A No.
Judith T. Terry, Town Clerkr-;:t ��� $10.00 - Residential
Town Hall, 53095 Main Road
p. O. Box 1179 cns< $25.00 - Non-Residential
Southold, New York 11971 O ®r-: :. ; �'
Telephone *14 .a0 .$
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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 :c/r-7 q9
OWNER NAME: QZ 18, t P}— � /'8 ELI h
OWNER MAILING ADDRESS: I .Is �� h�� �� r `b 1
OWNER PROPERTY ADDRESS: C/4- ,A- "ek P' lid
8-rcep Iv Po #Z.1-- pig( ? cLty
OWNER TELEPHONE NUMBER: 7 ( 6 0 C f
TAX MAP NO. : Section 31 Block 5 Lot 36
CROSS STREET:
TYPE OF SYSTEM: - -Septic Tank - New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: I °
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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Signatur f Applicant
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RECEIVED BY:
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Town Clerk's Office
DATE:
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