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JUDITH T. TERRY � = Town Hall, 53095 Main Road
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® �, 3 lY P.O. BOX 1179
TOWN CLERK
Lr, ;rr * Southold, New York 11971
REGISTRAR OF VITAL STATISTICS N r
MARRIAGE OFFICER , @� '4 Fax (516) 765-1823
�7® � 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. 1931-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KALLER, DOLORES H. •
Mailing Address 1 7895 SKUNK LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 7895 SKUNK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6001
Tax Map No. section 104.00 block 4 lot 24.000
Cross Street PINE TREE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FO( (
Town of Southold Q -,_ CSG Application No./ &,/
Judith T. Terry, Town Clerk
f } <: .G ! $10.00 - Residential
Town Hall, 53095 Main Road o *,�, y s.
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p. O. Box 1179 ‘P.
�.� f�` $25.00 - Non-Residential
Southold, New York 11971 O ®, ,�L f
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.
cP
Fee $ /c L
DATE
OWNER NAME: ,UO A. QR
OWNER MAILING ADDRESS: 7 8-9 5 c ' /A '/t'
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OWNER PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER: • (5-'/(0/7 -214 3 — 00/
TAX MAP NO. : Section ,/,',Z) Block ( Lot ZY
CROSS STREET:
TYPE OF,SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential js Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
0 (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
:i4.
ign. 'bre of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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