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Town Hall, 53095 Main Road
° - P.O. Box 1 179
�® � 44, Southold, New York 11971
JUDITH T.TERRY - _®� TELEPHONE
TOWN CLERK -n<>_://i- (516) 765-1801
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. 927-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAPLAN, Z. MICAH
Mailing Address 1 17815 SOUNDVIEW AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 17815 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1578
Tax Map No. section 51 .00 block 1 lot 5.000
Cross Street MT. BEULAH AVENUE
Date Of Last Pump Out 4/00/85
Issue Date: 11/21/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c$FiJL( '=
Town of Southold , Application No. 9127
Judith T. Terry, Town Clerk � �'' 4 �l Residential
Town Hall, 53095 Main Road . ,
P. O. Box 1179 � Non-Residential
Southold, New York 11971
Telephone _ (
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /b'
DATE ////U/rer
— OWNER NAME: $iea 4 Tl o /A.✓
OWNER MAILING ADDRESS: /1 g/ S� Soot/c///e4.) �e
"// //,7/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
039.0
TAX MAP NO. : Section ( Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New xistin��
esidential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7fr
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.)
Signatu 0 of Applicant
RECEIVED BYc: x�R�
� owQ n C r{1�s Offic -
DATE: NOV 21 1988
'town Clerk Souttio
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