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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 ® ®� Fax Fax (516) 765-1823
=__VA,=-4°4 $� ��” 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. 2093-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner EGERT, HERBERT AND LOUISE
Mailing Address 1 P. O. BOX 296
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 MANOR ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1273
Tax Map No. section 38.00 block 4 lot 5.001
Cross Street EAST GILLETTE DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFF CE OF THE TOWN CLERK .COFO(,r��.
Town of Southold �� CQG' , Application No..Q
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road c
P. O. Box 1179 cry =- •Er $25.00 - Non-Residential
Southold, New York 11971 O ® t*040' ' -1/Telephone 5 ' J
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /7j
DATE 3 !3/ 193
OWNER NAME: /--i-e-rber7 ' h.0 ztc.4,e ElerT
OWNER MAILING ADDRESS: 130)( 24' fo f Era-q— r cam, AL y 1/L/-3e
OWNER- PROPERTY ADDRESS: a•,r,jeLF jl 1457 Md}J i arJ •�. f/'99r 7
OWNER TELEPHONE NUMBER: 576 E V77 —102
TAX MAP NO. : Section Block Lot ZO' ' l
CROSS STREET: �-Ator
TYPE,O•F-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.)
/2/W7Signatureppilcant
Tow " rk s Office
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