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OFFICE OF THE TOWN CLERK CliFuU(l+
Town of Southold
Judith T. Terry, Town Clerk-
Town Hall, 53695 Main Road
P. 0. Box 1179 cn
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation; Permit No. 276 Residential X
Fee $ 10.00
Non-Residential—
Septi c
on-ResidentialSeptic Cesspool X
NAME OF OWNER: Jean W. Erath
OWNER MAILING ADDRESS: Gin Lane
Southold, New York 11971
OWNER PROPERTY ADDRESS: Gin Lane
Southold New York
OWNER TELEPHONE NUMBER: 516-765-3940
TAX MAP NO. : Section 88 Block 3 Lot 6
CROSS STREET: Main Bayview Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terry
Southold Town Clerk
DATE: April 13, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK :F�
Town of Southold 0��� �C®� Application No
Judith
Judith T. Terry, Town Clerk `
Residential
Town Hall, 53095 Main Road -�
P. 0. Box 1179 cry _ 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 $ Id-
DATE
OWNER NAME: �J ,t/ L✓ ��'fi/f
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 3 %
TAX MAP NO. : Section Block Lot
CROSS STREET: N //\/ 3e y V a G l/)
TYPE OF SYSTEM: Septic Tank New Existing
i
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.)
C �
Si'ainature of AplSlic ht
RECEIVED BY:
RECEIT wn Clerk's Office
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DATE: A �
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Town Clerk Southold
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