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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p r= P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER yQ ®N' , Fax (516) 765-1823
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Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2071-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LANG, GLORIA E.
Mailing Address 1 P. O. BOX 726 -
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1260 BAY HAVEN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3553
Tax Map No. section 56.00 block 5 lot 1 .003
Cross Street BUDD'S POND ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/09/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OII ICE'OF THE TOWN CLERK PFFD •-
Town of Southold _% Application No. o9'Z�9
Judith T. Terry, Town Clerk • Jrk i ►�' f
Town Hall, 53095 Main Road �y ' $10.00 - Residential
P. O. Box 1179 v' v, -`.}` i • $25.00 - Non-Residential
Southold, New York 11971 O ®.*-i s •�`
Telephone /5Co.( 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
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OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 /c;-40
DATE )\'fr/sc;(6 (7cp
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OWNER NAME: dre, ti )4,'‘At
OWNER MAILING ADDRESS: iSpe )C 72CQ.)- (t/L2 /\(.-'/‘ ( 1 ?f
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- OWNER--P..0. ERTY--ADDRE.,S: -,_- -
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OWNER TELEPHONE NUMBER: F.1/4176'-- 767"-3,-\173
TAX MAP NO. : Section 5— C Block 5— Lot
CROSS STREET:—
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TYPE- Of- SYS-EM: Septic Tank - - New Existing /
Cesspool New Existing v
Residential Non-Resid-ntial
DATE OF PREVIOUS PUMP-OUT: Vhf ISS •I
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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 Applic 1t
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RECEIVED:,BY ,, , _
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