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JUDITH T. TERRY , Town Hall, 53095 Main Road
TOWN CLERK ® � t P.O. Box 1179
REGISTRAR OF VITAL STATISTICS (I .�` Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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ti� 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. 1981-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner H I LB I G, NANCY W.
Mailing Address 1
Mailing Address 2 1700 PARKWAY
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1700 PARKWAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5303
Tax Map No. section 70.00 block 10 lot 50.001
Cross Street BEACHWOOD ROAD
Date Of Last Pump Out 0/00/81
•
Issue Date: 10/01/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK ® �
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P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS R .%`' Southold, New York 11971
MARRIAGE OFFICER k, O •i� Fax (516) 765-1823
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®f Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1981-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HILBIG, NANCY W.
Mailing Address 1
Mailing Address 2 1700 PARKWAY
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1700 PARKWAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5303
Tax Map No. section 70 block 10 lot 5.001
Cross Street BEACHWOOD ROAD
Date Of Last Pump Out 0/00/81
Issue Date: 10/01/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c�VFFULA-
Town of Southold ��� ;,.; YC'� Application No. �� g/
Judith T. Terry, Town Clerk �` x' , 1
Town Hall, 53095 Main Road fa .:-::=- :',,':' �C $10.00 - Residential L
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p. O. Box 1179 crs � 2 `- i z $25.00 - Non-Residential
Southold, New York 11971 %,t;•,- ®, ''''_. �$
Telephone �1 qd It '��
(516) 765-1801 •"
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE i • X/92 •
OWNER NAME: A4 9441061 CO- H,L 31 -
OWNER MAILING ADDRESS: /700 /�A,e4-"& - -
S'olt7lOL1� it) 1/ 97/
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OWNER PROPERTY ADDRESS: - s4-4/ .ts R3b1/ -
OWNER TELEPHONE NUMBER: 765.- 53b3
TAX MAP NO. : Section '2/0 Block /6 Lot 50 . /
- CROSS STREET: e,
TYPE OF,SYSTEM: Septic Tank New Existing -
Cesspool New Existing i ----
-
- Residential Non-Residential
iiia;,-
DATE OF PREVIOUS PUMP—OUT: --'"'-="= =,—
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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gnature of Ap nt
RECEIVED .BY: Vim-/✓"` � - ., -
Town Clerk's Office
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