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Town Hall, 53095 Main Road
4� ;,� P.O. Box 1179
�=� Ok �. its Southold, New York 11971
. 7.0o'' FAX(516)765 1823
JUDITH T.TERRY - yi�� " TELEPHONE(516)765-1801
TOWN CLERK
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. 1408-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAWKINS, SARA L.
Mailing Address 1 2065 MINNEHAHA BLVD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2065 MINNEHAHA BLVD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1912
Tax Map No. section 87.00 block 3 lot 55.000
Cross Street NAKOMIS ROAD
Date Of Last Pump Out 0/00/00
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Issue Date: 3/09/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFULJ'
Town of Southold Q CQ Application No. NO
Judith T. Terry, Town -Clerk 441 , ,, Q1'."
Town Hall, 53095 Main Road fr $10.00 - Residential
-
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P. O. Box 1179 cn �={ i `
., ti �. ,� �� $25.00 - Non-Residential
Southold, New York 11971 O0 _•N . ���J
Telephone = 1 `�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE0/ ei/q o
'OWNER NAME: SA /\ ) 1\-k)<1 I'05 •
OWNER MAILING ADDRESS: &OtTS M4 nn( /yaw 61u(1.
OWNER PROPERTY ADDRESS: cu'ri`e UJ nJ '{
OWNER TELEPHONE NUMBER: (5 )( ) -hos -) q
TAX MAP NO. : Section ? '7 Block 3 Lot rJ 5
CROSS STREET: . ii Jtz ic 0 )11/ s
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool \/. New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ) / 101 go
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.)
•
61.1,
Signa re of A.plicant
RECEIVED BY:
Town Clerk's Office
DATE:
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