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Town Hall, 53095 Main Road
P.O. Box 1179
44
Southold, New York 11971
JUDITH T.TERRY ®�� TELEPHONE
TOWN CLERK �� (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. 806-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KEARNEY, MARIE
Mailing Address 1 146 YALE STREET
Mailing Address 2
City St Zip ROSLYN HEIGHTS NY 11577-0000
Property Address 1 655 BIRCH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-621-2962
Tax Map No. section 59. 00 block 2 lot 8.000
Cross Street SOUNDVIEW AVENUE
Date, Of Last Pump Out 0/00/00
Issue Date: 8/31/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
II Iii
OFFICE OF THE TOWN CLERK ,C3\„ -
Town of Southold , � ��G Application No._,T46
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Residential
P. O. Box 1179 n' 4.
�;� � Non-Residential
Southold, New York 11971
Telephone _°I kid, O
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. (y
Fee $ /O .A '/ b
DATE -T h - s ?S
OWNER NAME: PnPRIE '<ERR .,IE V
OWNER MAILING ADDRESS: J'/( yelLE Sri
Tps hy, l-�TS 1.E 77
OWNER PROPERTY ADDRESS: (055 6 1 is i\D
&)«a 14 o L D a '( 8 A qf 7 I
OWNER TELEPHONE NUMBER: 7 1 - ,Q c
TAX MAP NO. : Section Block Lot O
CROSS STREET: 6f)()1,wo 1a=
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1 New Existing
Residential p Non-Residential
DATE OF PREVIOUS PUMP-OUT: \\J t7N! --
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.)
osA)2-1.-
gtiae
Signature o`f Applican
RECEIVED BY:4.4 ,
Town Q'lerk's Office
DATE: ECIIVLLT
AUG 1966
Town Ciotti Saifilaig
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