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Town Hall, 53095 Main Road
v'�® �®�-��• P.O. Box 1179
� �0. Southold, New York 11971
JUDITH T.TERRY ,00 FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1508-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ELFERS, HENRY C.
Mailing Address 1 P. O. BOX 1136
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4380 ROBINSON ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3641
Tax Map No. section 81 .00 block 3 lot 6.000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/27/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE QF THE TOWN CLERK ,•PFFD '
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Town of Southold
��� �CQG Application No. '� 5
Judith T. Terry, Town Clerk k^ ':'*� $10.00 - Residential L/
Town Hall, 53095 Main Road -
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P. O. Box 1179 u' -.'t �`r ^` ` $25.00 - Non-Residential
Southold, New York 11971 O` ' O�',��`
Telephone ,( y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ •
DATE(h 15 90
OWNER NAME: %T &-/1gy C- ,
OWNER MAILING ADDRESS: Po o � 'e (/36
,s6 ii7 / il (,b ;, /79 *
OWNER PROPERTY ADDRESS: 2/3/-6 �,.A .„J26e -
�r
OWNER TELEPHONE NUMBER: / -7(c'-- 76 r4-/
TAX MAP NO. : Section F7 -3 - d Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 492-
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7/11--x,
�Lt -
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.)
Signa of Ap icant
RECEIVED BY:
Town Clerk's Office
DATE:
AY
7
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PARADIBE POINT
P.O. BOX 113
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