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f' Town Hall, 53095 Main Road
grt ®v ��` P.O. Box 1179
-:�(� " Southold, New York 11971
JUDITH T.TERRY �� .//00°�I 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. 1142-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HOLLOWELL, KEN
Mailing Address 1 BOX 246
Mailing Address 2
City St Zip CREENPORT NY 11944-0000
Property Address 1 SOUND DRIVE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0197
Tax Map No. section 33.00 block 4 lot 33.000
Cross Street TASKER LANE
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,, OI IIS i'
OFFICE OF THE TOWN CLERK cp-FRA'.
Town of Southold , Application No./7/4
Judith T. Terry, Town Clerk akt, Residential
Town Hall, 53095 Main Road
:
P. O. Box 1179 = En
+f• , Non-Residential
- Southold, New York 11971 ��`
Telephone _�( �►��,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ •
DATE Cl /;,6'%•
OWNER NAME: 4 //trnhPeII
OWNER MAILING ADDRESS: 3O 29
cRee 'p a r, W ^Y
OWNER PROPERTY ADDRESS: Stf,t4Aiffiei °
G Re eA'fiaR) 4 Y • ) 19999
OWNER TELEPHONE NUMBER: f7/ 7 — 0 / V7
TAX MAP NO. : Section 3 Block l Lot 3�
CROSS STREET: daD.
TYPE OF SYSTEM: Septic Tank New ' - Existing
Cesspool New Existing
Residential ,I/ Non-Residential
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.) _-
Si ure of Appliant
RECEIVED BY:
Town Clerk's Office
DATE:
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