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-�: ;�' Town Hall, 53095 Main Road
C rte® O .F .r P.O. Box 1179
�®� � ,0��I Southold, New York 11971
JUDITH T.TERRY -'-.,,,,, %'�.° FAx(516)765-1823
TOWN CLERK TELEPHONE(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. 1422-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HENN, ROBERT
Mailing Address 1 TEDESCHI, JOANNE
Mailing Address 2 1050 SMITH ROAD
City St Zip PECONIC NY 11958-0000
Property Address 1 1050 SMITH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-7241
Tax Map No. section 98.00 block 3 lot 28.000
Cross Street INDIAN NECK
Date Of Last Pump Out 0/00/00
Issue Date: 3/19/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold O�O � . �&. Application No. / off
Judith T. Terry, Town Clerk ;= " y ;•
Town Hall, 53095 Main Road '. y'. $10.00 - Residential
P. O. Box 11791,,!57.4%.111cn `s i ` -
$25.00 Non-Residential
Southold, New York 11971 O "�'' �J •
Telephone *0,( t •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $ •
DATE IS, Mn ILC1 / 990
OWNER NAME: ry a- k en9 n cue. IE:ck6Cwc c •
•
OWNER MAILING ADDRESS: Ib 5O SA4iTl ezA-D
P Co Pei IC-
OWNER PROPERTY ADDRESS: S y \ VYl e _
OWNER TELEPHONE NUMBER: �1 47Z41
TAX MAP NO. : Section 098 ' 00 Block O3° ®O Lot 0 Z.S ° 00
CROSS STREET: I ha, (OW( ne-C 1C----_
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Re idential
DATE OF PREVIOUS PUMP-OUT: g/C9N11.
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.)
Ws:9,410,-yule) r a t
Signature of A Dant
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RECEIVED BY:
Town Clerk's Office - -
DATE: e,
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