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fl Town Hall, 53095 Main Road
'^ P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ®� acs' i� TELEPHONE
TOWN CLERk (516) 765-1801
REGISTRAR Oh VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 808-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HIDDINK, ELIZABETH
Mailing Address 1 614 BAILEY AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 614 BAILEY AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1088
Tax Map No. section 34. 00 block 4 lot 5. 000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 9/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3\\FFa(,rl'=
Town of Southold � Application No.
Judith T. Terry, Town Clerk .` 4-.40' :t
Town Hall, 53095 Main Roads �s �' :'� Residential
,tU'.e' .�1t`Sf -[ a7'y4
P. O. Box 1179 v' t ,4 � ; Non-Residential
Southold, New York 11971 �i� -;1%—$- 0 ��`
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Telephone ,(
Ne
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /6 ,
DATE 9/1 71PY
OWNER NAME: & -rX/
OWNER MAILING ADDRESS: /2 I3i )J -
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OWNER PROPERTY ADDRESS: ,��
OWNER TELEPHONE NUMBER: 5/c/4e77pO gs
TAX MAP. NO. : Section `3 T Block Lot
CROSS STREET: RT,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool l/ New Existing V
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: I%t. c / 7/ /9
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 A
pplicant
RECEIVED BY:
6261folle-NrLii (Gerk's O fice
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DATE:
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