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P.O. Box 1179
-r_V%� � ,i Southold, New York 11971
JUDITH T.TERRY �'�� ���
��iri7 lG'/'�' FAX(516)765-1823TQWN CLERK TELEPHONE(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. 1484-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LANDERA, ROBERT R.
Mailing Address 1 BOX 316
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 33650 ROUTE 48
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2666
Tax Map No. section 74.00 block 3 lot 12.000
Cross Street PECONIC LANE
Date Of Last Pump Out 0/00/85
Issue Date: 6/15/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c��FF-�](x�'-
Town of Southold � CQG' , Application No. 1 1/44 34
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road y -
P. O. Box 1179 `,.ti ` „ = ; $25.00 - Non-Residential
Southold, New York 11971 115,' 17%
Telephone _O1 ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
dl
Operation Permit No.
Fee $ 10 , 0-0
DATE
OWNER NAME: iy ( S t 7- L 'kt4 di
OWNER MAILING,ADDRESS: 55 4 co 6 a 3 f G
OWNER PROPERTY ADDRESS: 33 c
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OWNER TELEPHONE NUMBER: 762171 7?���
TAX MAP NO. : Section 2 Block Lot ! 9--
CROSS
CROSS STREET: (P,�e_e, (C ))1Te
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1 t
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.)
- - /Via-72.
6,,,,a,\
Signature o Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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