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Town Hall, 53095 Main Road
�'® ®�-i P.O. Box 1179
`402 `1)x,0' Southold, New York 11971
JUDITH T.TERRY <.,,,,,,,- FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7651801
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. 1570-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JOHNSON, JANET AND JOSEPH
Mailing Address 1 210 NORTH KINGS AVENUE
Mailing Address 2
City St Zip NORTH MASSAPEQUA NY 11758-0000
Property Address 1 1080 OAK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-795-7710
Tax Map No. section 80.00 block 2 lot 6.000
Cross Street WEST SHORE DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/24/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COMA' - _ \
Town of Southold � C'� '_ Application No.
Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road -� } $10.00 - Residential, ,_
P. 0. Box 1179 vs ;;" '`��` $25.00 - Non-Residential
Southold, New York 11971 OO c'`"..�O '�`�
Telephone ,( `, '�
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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: a- To s e L NI d d1/4-3 '
OWNER MAILING ADDRESS:a/d aU • I�r c
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OWNER PROPERTY ADDRESS: /O rum
OWNER TELEPHONE NUMBER: 5/6 - i9'` 77(0
TAX MAP NO. : Sectiona OP ) Block c 0 Lot 6® b OQ O
CROSS STREET:ieefrSalk (.0 e c rYA ®/L4=2 a2 I I/-e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Us4 fOLO/v irnion 77%f3
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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Sig atur- of Applicant
RECEIVED BY: -
Town Clerk's Office
DATE:
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MR. & MRS. J. JOHNSON
210--NO. KINGS AVE.
MASSAPEQUA, N.Y. 11,758
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