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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
`� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS O �
MARRIAGE OFFICER ® ..��' Fax (516) 765-1823
�/� 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. 1870-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner EGAN, JUNE & FERRELL, ROBERT
Mailing Address 1 57605 ROUTE 48
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 57605 ROUTE 48
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-9474
Tax Map No. section 44.00 block 2 lot 6.000
Cross Street ALBERTSON LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/09/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL),
•
OIEICE OF THE TOWN CLERK ec \VFO(ir"-=
i' Town of Southold OO CQG': Application No. /t76
Judith T. Terry, Town Clerk $10.00 - Residential
� a�< a/ -
Town Hall, 53095 Main Road �-� �-��s � l
P. O. Box 1179crs , ' 25.00 - Non-Residential
Southold, New York- 11971 0 � `� $
• Telephone 0 Net/
(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: (JO 11 e, C CLo {�� r� �e k Fe I
OWNER MAILING ADDRESS: 76 05 R i s-
� Yeeh a )-Cf
OWNER PROPERTY ADDRESS: 576 0 5 i+
re, ,, r a >cc-- m . / /7V-4-/
OWNER TELEPHONE NUMBER: J .�] 7 - 9417121-
TAX MAP NO. : Section Block Lot !�
CROSS STREET: /1 i7ca1��� o� 4-a h e
TYPE OF SYSTEM: Septic Tank 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 oj\pplicant
RECEIVED BY:
Town CI rk's Office
DATE: -
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