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OFFICE OF THE TOWN CLERK ' icOFO[KC�G li
Town of Southold _
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Judith T. Terry, Town Clerk � , ` ' -,
Town Hall, 53095 Main Road 'n j
P. O. Box 1179 C�
Southold, New York 11971 FO 0�-
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Telephone _ 1 'N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT li
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 123 Residential g
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Pauline Israel
OWNER MAILING ADDRESS: P.O. Box 801
Greenport, New York 11944
OWNER PROPERTY ADDRESS: 12 Osprey West Road
Greenport, New York
OWNER TELEPHONE NUMBER: 516-477-0350
TAX MAP NO. : Section 35 Block 6 Lot
CROSS STREET: Cleaves Point: Maple Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing
Residential g Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1986
Judith T. Terr
Southold Town Clerk
DATE: November 5, 1986
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(TOWN SEAL)
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OFFICE „„„
OFFICE OF THE TOWN CLERK _
Town of Southold .� � Q(x`Q Application No. /23
Judith T. Terry, Town Clerk .���e ^
Town Hall, 53095 Main Road
Residential
K K V M
P. O. Box 1179 crs ,z=` $ ` ' :' Non-Residential
Southold, New -York 11971 O ' ” ��
Telephone ( y y► ; . '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
1069f o'r
04
0 ®a OPERATION PERMIT
V cNe- SEPTIC TANK or CESSPOOL
Operation Permit No. /0.23
Fee $ /0 -
JI
. _ DATE
OWNER NAME: eRt,tj l)v e. L
I
OWNER MAILING ADDRESS: /t, 0.4)(9, k3 sT•eQ. ?.03016 gOl
G-redem por-t I ) t) 99V -
OWNER PROPERTY ADDRESS: 1 Ospre. INe.sT boa
Crre,evv pert PL t) q yyl
OWNER TELEPHONE NUMBER: 51(9- y77- 3 5O
TAX MAP NO. : Section 0 3 c Block G Lot
CROSS STREET: CLeQOe,S ?OS4042-
TYPE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 17/
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: LSI I ! O�/b
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.)
i
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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EDUCATION LAW.
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