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JUDITH T. TERRY z Z Town Hall, 53095 Main Road
TOWN CLERK " •
p T , P.O. Box 1179
REGISTRAR OF VITAL STATISTICS crs
Southold, New York 11971
MARRIAGE OFFICER 0. O�. ,. Fax (516) 765-1823
��01 ltv 0" Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
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Operation Permit No. 2055-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner EDSON, LEWIS L.
Mailing Address 1 P. O. BOX 1526 -
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2 XMAS TREE FARM - HOUSE ONLY
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-765-2288
Tax Map No. section 102.00 block 2 lot 16.000
Cross Street PEQUASH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN• CLERK os CLERK
Town of Southold CQG' Application No a,S--
ze
Judith T. Terry, Town Clerk
�vx 7 $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 u' $25.00 - Non-Residential
Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL -
Operation Permit No.
Fee $
DATE
OWNER NAME: /9-kJ/Ss / 4--
OWNER MAILING ADDRESS: o / 3~ Z 0
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OWNER PROPERTY ADDRESS: iv/ /F/if
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OWNER TELEPHONE NUMBER: 7 6 S-- Z P
TAX MAP NO. : Section tQ Block Z Lot
CROSS STREET: 7,—e Gtiyf7,/ A e .0, s'�j�UGY
TYPE OF SYSTEM: Septic Tank v New 'Existing
Cesspool New Existing
Residential 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:
Town Clerk's Office
DATE:
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