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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK = 1 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS r�� -� -�,,:,� -;-� `�' ,%•
Southold New York 11971
MARRIAGE OFFICER i�' Fax (516) 765-1823�moi/, �0 ' 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. 1647-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JESTER, CLARENCE
Mailing Address 1 3875 OAKLAWN AVENUE EXT.
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 FRONT STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-765-3256
Tax Map No. section 45.00 block 4 lot 2.000
Cross Street MOORE'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFF) E OF THE TOWN CLERK C�v�FO(�'�'- _
Town of Southold % ". CQG Application No. ga T
Judith T. Terry, Town Clerk . �. •, +/
ate-.• � •
�_ ' ix: :.' .G $10.00 - Residential
Town Hall, 53095 Main Road . . -
crs j ,r' $25.00 - Non-Residential
P. O. Box 1179 ..� ��? � �
Southold, New York 11971 O
Telephone ,Oj 1714
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE (ylwrc4 � lCjF /
OWNER NAME: C' �.ck4-e4c,e f Sr e (-
OWNER MAILING ADDRESS: 3 g ?J C)G CL.--ww_--) x =
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OWNER PROPERTY ADDRESS: -
a -t- Pori 62-) �
OWNER TELEPHONE NUMBER: ,5j (o - )(s- 3i5'C
TAX MAP NO. : Section s^ Block Y Lot Z C`1a - I l)
CROSS STREET: /'ri 0-05 C rS LG-P1
TYPE OF SYSTEM: Septic Tank ' New Existing
Cesspool // New Existing l�
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.)
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Signature oliApplicant
RECEIVED BY:
Town Clerk's Office
DATE: _
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