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JUDITH T. TERRY � ,
" Town Hall, 53095 Main Road
TOWN CLERK 5J P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ;, y fy Southold, New York 11971
MARRIAGE OFFICER 4 • ) '7 Fax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1600-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KNOWLES, ANNA L.
Mailing Address 1 BOX 190
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 INDIAN NECK LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-6752
Tax Map No. section 86.00 block 6 lot 25.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERKc�vFFo(,rC /e)a-.)
Town of Southold •4. '�� Application No.
Judith T. Terry, Town Clerk _ '' 4z5. y
Town Hall, 53095 Main Road
i .G $10.00 - Residential
P. O. Box 1179 cn �'� �� w', . h�i ` $25.00 - Non-Residential
Southold, New York 11971 O ® .
Telephone I44NN�
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ `t)'Uv
DATE r l I qv
'OWNER NAME: 105i ) a r eS n b tot ,I 6 •
OWNER MAILING ADDRESS: I?) I q �eZav1i6 11.; be
OWNER PROPERTY ADDRESS: n J ( 1-1 � �G�f -{-. 61
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OWNER TELEPHONE NUMBER: -7:; N p q S�a,
TAX MAP NO. : Section gia Block le Lot
CROSS STREET: Mal ) Rd -
TYPE
d -TYPE OF SYSTEM: Septic Tank New Existing 1t/
Cesspool New Existing Y
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: !/1 if el
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.)
Signature of Applicant
RECEIVED BY: X
REcevTown Clerk's Office
DATE: DEC I iS
Town Clerk Southofd
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