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r li Town Hall, 53095 Main Road
4v ems O �N, �� P.O. Box 1179
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��� Southold, New York 11971
JUDITH T.TERRY ,�`r - � (5 TELEPHONE
TOWN CLERK
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. 3584-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HALLOCK, LYNNE
Mailing Address 1 WEBSTER, KEVIN
Mailing Address 2 7 MIDDLETON ROAD
City St Zip GREENPORT NY 11944-0000
Property Address 1 7 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-4047
Tax Map No. section 40.00 block 5 lot 2.000
Cross Street BENNETT ROAD
Issue Date: 2/11/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 10F0(.,(
Town of Southold �® CSG=� Application No. 3
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Judith T. Terry, Town Clerk �` v,', =\
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn .r1 '` `` $25.00 - Non-Residential
Southold, New York 11971 OEi� y j ,. �`,
Telephone '
."0./At. � .'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ '
DATE . Comudl✓1 0`JRR7
OWNER NAME: LTnKe_ NLt\.oCIC Keo►v► LJe, oCfe-V
OWNER MAILING ADDRESS: —7 WliAdIt t- , �oLj
Nil WW1
OWNER PROPERTY ADDRESS : wg. 04 alp-ANL
OWNER TELEPHONE NUMBER: Lem—oy1 _
TAX MAP NO. : Section HQ ' Block 5 Lot o�
- CROSS STREET: - Re mA
TYPE-SOF .SYSTEM: Septic 'Tank - = r - New Existing
Cesspool _New Existing `
Residential Non-Residential
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.)
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Signature of Applicant
RECEIVED BY•. / s1 � -
Town elerk's Office
DATE - •
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/ - ; 7 MAP OF PROPErTY •l',
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