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OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk 1
Town Hall, 53095 Main Road c�
P. 0'. Box 1179 Ln
Southold, New York 11971 4
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 54 Residential XX
Fee $ 10.00 Non-Residential
Septic Cesspool XX
NAME OF OWNER: Samuel Epstein
OWNER MAILING ADDRESS: P.O. Box 1042
Southold New York 11971
OWNER -PROPERTY �A-DDRESS.: - -Goose-Creek ,-Lane
,-Lane
Southold, New Yo rk
OWNER TELEPHONE NUMBER: 516-765-2467
TAX MAP NO. : Section 78- Block g Lot 5.1
CROSS STREET: North Bayview Road Ext.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX New Existing XX
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: Fa II of 1985
Judith T. Terr
Southold Town Clerk
DATE: September 19, 1986
(TOWN SEAL)
F�
OFFICE OF THE TOWN CLERK C��F
Town :of Southoldy CQ� Application No,_�L/
Judith T. Terry, Town Clerk 4
Town Hall, 53095 Main Road :e Residential
P. 0. Box 1179 v' Non-Residential
Southold, New York 11971 O
Telephone0.� y Y►���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for-
OPERATION
or-OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ � —
DATE //-"
OWNER NAME: 114 Ui✓L E?:�S 7E:_/A
OWNER MAILING ADDRESS: P0. (�U K 0
o v77-�o L_b , l C(7�
OWNER PROPERTY ADDRESS: C�of1St=
OWNER TELEPHONE NUMBER: C��C�J 76 3'
TAX MAP NO. : Section �j Block Lot j
CROSS STREET: 0&1V /
TYPE OF SYSTEM: - Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: j"� P / Ivey
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
DAT E:
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