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cry Mi , Town Hall, 53095 Main Road
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JUDITH T. TERRY '��ArAre o'1,°1TELEPHONE
TOWN CLERK (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. 1076-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HEFFERNAN, PAUL
Mailing Address I NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000 -
Owner Telephone No. 516-765-2700
Tax Map No. section 135.00 block 2 lot 18.000
Cross Street GOLDIN LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I�II�
OFFICE OF THE TOWN CLERK rc��FFp(,r�'• -
Town of Southold '2' Application No. /67,
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road o a,*« ,; -C Residential
P. O. Box 1179 u' Non-Residential
Southold, New York 11971 0
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Telephone = ( •
(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: PR-IA.__ .ktf feela
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OWNER MAILING ADDRESS: N �� , -RI tkgb
OWNER PROPERTY ADDRESS: 5--1Q Ar\ \T
OWNER TELEPHONE NUMBER: 7C;_tr---.9-_7 /®-O
TAX MAP NO. : Section rt 35— Block 2, Lot f
CROSS STREET: C Ci\ DIN
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ^.
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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 clo est read.)
/1 J.)/ )fa r�f pplicant
RECEIVED BY: .
Town Clerk's Office
. DATE:
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