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r; Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
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JUDITH T.TERRY ' mss' , � ' TELEPHONE
TOWN CLERK Ail 1- (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERIC
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 826-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner KIMBUS, JAMES
Mailing Address 1 1375 GIN LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1375 GIN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5468
Tax Map No. section 88. 00 block 4 lot 11. 000
Cross Street WATERSEDGE WAY AND MIDWAY
Date Of Last Pump Out 0/00/00
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Issue Date: 9/12/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c,� FO(,(� '
Town of Southold � t , -� CO - , Application Nde
Judith T. Terry, Town Clerk \` ,; ` K.
° �t �c 1 Residential
Town Hall, 53095 Main Road -Tr ``'" .
P. O. Box 1179 a k: �A i
CT9 2}` .mom �`�< .�fiS., \
Southold, New York 11971 0' t IV ��J� Non-Residential
Telephone :�( Itto
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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 [,AleTC'
OWNER NAME: j 4i,(.FS , i t
OWNER MAILING ADDRESS: 1 9 95- (.;•11,1 Lcyi .'
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OWNER PROPERTY ADDRESS: SAME
OWNER TELEPHONE NUMBER: 74. '= ,5Yeg:)
TAX MAP NO. : Section b Block of Lot 11
CROSS STREET: tA)q-.L 1 LcL._�
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential < Non-Residential
DATE OF PREVIOUS PUMP-OUT: CL nk ,rpry
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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Signature of Applican
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RECEIVED BY:
Town Clerk's Office
DATE: