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$ Town Hall, 53095 Main Road
® , kr$, P.O. Box 1179
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1\bY,1 Southold, New York 11971
JUDITH T.TERRY it, 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. 1457-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HULSE, WALTER T.
Mailing Address 1 145 DOGWOOD LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 145 DOGWOOD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2549
Tax Map No. section 54.00 block 5 lot 25.000
Cross Street KENNYS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK e crOFOur
Town of Southold n t Application No. /4 S "
Judith T. Terry, Town Clerk ��,� '
Town Hall, 53095 Main Road ° u �`� $10.00 - Residential
P. O. Box 1179 �`x- ' s
. �,5 � $25.00 - Non-Residential
Southold, New York 11971 O ® --tib OBJ
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: V� �'�� 1� T Pu bs e • •
OWNER MAILING ADDRESS: 5- vebu it -0 t -/y-
- --P t
OWNER PROPERTY ADDRESS: 42_113,0-0 -
OWNER TELEPHONE NUMBER: 7 'mow 2c
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 3 New Existing
Residential 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.)
Signature of Applicant
RECEIVED BY: L-xa ._
awn Cl k's Of ice
DATE: MAY 14199®
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