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OFFICE OF THE TOWN CLERKFFU[K
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Town of Southold Q Y .� , a4
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road k _ =;
P. 0. Box 1179 :� ' 4t "
Southold, New York 11971
Telephone = Oj
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 277 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Margaret S. Katzenberq
OWNER MAILING ADDRESS: 2125 Town Harbor Lane
Southold, New YOrk 11971
OWNER PROPERTY ADDRESS: 2125 Town Harbor Lane
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3509
TAX MAP NO. : Section 66 Block 1 Lot 31
CROSS STREET: Terry Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: January 12, 1987
Judith T. Terry U
Southold Town Clerk
DATE: April 15, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLE-RK - c��FFO(,(���"
=< own of Southold Q ;-� C'� � Application No. c).2.-
Judith
2Judith T. Terry, Town Clerk '` �.
Town Hall, 53095 Main Road , ,t;:� 7 Residential ✓
btu
P. O. Box 1179 cn 1.4j14 *Z. �� Non-Residential
Southold, New York 11971 '
Telephone
(516) 765-1801 _ 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE j Lf /a, /? /1
OWNER NAME: r2td
OWNER MAILING ADDRESS: o2/ oZ.f -7 4,„,(/„,2 49,„p
OWNER PROPERTY ADDRESS: /-et-44-4..e_.____
OWNER TELEPHONE NUMBER: 57 S'- 33'^ay
TAX MAP NO. : Section 1p Block / Lot /
CROSS STREET: -v,� �_
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 17 Non-Residential
DATE OF PREVIOUS PUMP-OUT: pat__4_-• ( ', ("( d7
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.)
JSignature Applicnt
RECEIVED BY-
Tow i
lerk's Office
DATE:
I
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