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JUDITH T. TERRY ► e� Town Hall, 53095 Main Road
TOWN CLERK ,• P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
F ,1" Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1718-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HERING, ROBERTA L.
Mailing Address 1 45475 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 45475 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3158
Tax Map No. section 75.00 block +'2 lot 12.000
Cross Street MAPLE AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/02/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•0 ' "I
OFFICE' OF THE TOWN CLERK �FFOL,r
Town of Southold �� CQ Application No. t'7/
Judith T. Terry, Town Clerk t . �+
Town Hall 53095 Main Road -� 1 $10.00 - Residential
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P. O. Box 1179 to 174-g� ���� �$ 25.00 - Non-Residential
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Southold, New York 11971 ,� _L $
Telephone 40.( . Y►�0 .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
1
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 1\J \ \ \° °c \
OWNER NAME: 9'w\ (:),) \--\�
OWNER MAILING ADDRESS: Wrjy ) 5
S l
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7 ( 5-
TAX MAP NO. : Section 5 Block Lot a•
CROSS STREET: ' ?\� M 9- Lam �k\y ov-N \./V\ '10
TYPE OF SYSTEM: Septic Tank - New - Existing
Cesspool ‘/ New Existing
Residential •V Non-Residential
DATE OF PREVIOUS PUMP-OUT: .\ \e\cA\
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.)
Signature of Applican
RECEIVED BY:
Town Clerk's Office
DATE:
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