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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
�' Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �� Fax 516 765-1823
MARRIAGE OFFICER - ( )
�� •is 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. 1816-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner J I MEN EZ, HI LDA
Mailing Address 1 P. O. BOX 571
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 36725 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6970
Tax Map No. section 85.00 block 2 lot 12.002
Cross Street SKUNK LANE
Date Of Last Pump Out 0/00/00
Issue Date: 12/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.27
OFFICE OF THE TOWN CLERK iC3UFFUL- "-_ cation /L
L liNolo 1
Town of Southold � �� -� . Q A pp
Judith T. Terry, Town Clerk •` Agi4
'° .•c 1 $10.00 Residential
Town Hall, 53095 Main Road � � ;.��� .
p. O. Box 1179 v' r; 1� �`' $25.00 - Non-Residential'
Southold, New York 11971 O�® -�`
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Telephone 4,0.(A $�•
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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
•
OWNER NAME: / /i /qhi
OWNER MAILING ADDRESS: IP°'(9 • ao S°7/
OWNER PROPERTY ADDRESS: 3 47 , S ' & id.d 0.14 lio? /42 rd.�,_
OWNER TELEPHONE NUMBER: " 7? ?
TAX MAP NO. : Section IV 00 s5 Block OOO , Lot O f P, - a
CROSS- STREET: S U:h 'C
TYPE OF SYSTEM: -Septic Tank New Existing
• Cesspool New Existing
Residential A/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1— c7/ -
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:
(Town- Clerk's Office
DATE: - - - -