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JUDITH T. TERRYc., Town Hall, 53095 Main Road
TOWN CLERK P.O.(1, Box 1 179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER
G Fax (516) 765-1823
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® �� 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. 1943-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HORNE, HELENE D.
Mailing Address 1 4695 SOUTH HARBOR ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4695 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2680
Tax Map No. section 87.00 block 1 lot 8.000
Cross Street H I AWATH I A PATH
Date Of Last Pump Out 0/00/89
Issue Date: 7/14/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3VFFD(x le?
Town of Southold �� CQG' Application No.
Judith T. Terry, Town Clerk % g
� �� �zt. ;•� �G 7 $10.00 - Residential 1/
Town Hall, 53095 Main Road t
P. O. Box 1179 u' 1"`' z
$25.00 - Non-Residential
Southold, New York 11971 O• •4
Telephone : 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. !t"9 V4
Fee
DATE
OWNER NAME: Helene D. Horne
OWNER MAILING ADDRESS: 4695 South Harbor Road —
Southold, NY 11971
OWNER PROPERTY ADDRESS: Same
OWNER TELEPHONE NUMBER: 516-765-2680
TAX MAP NO. : Section 87 Block 1 Lot 8
CROSS STREET: Hiawathia Path
TYPE OF SYSTEM: Septic Tank New Existing x
Cesspool New Existing x
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1989
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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Signature of Applicant
RECEIVED BY: /I/
Town Clerk's Office
DATE: -7/// / 9 -
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