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�' ' Town Hall, 53095 Main Road
JUDITH T. TERRY
TOWN CLERK ® t P.O. Box 1179
REGISTRAR OF VITAL STATISTICS (� $ Southold, New York 11971
MARRIAGE OFFICER � � ,a '1` Fax (516) 765-182365-1
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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. 1773-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner LANCER, WAYNE AND DEBORAH
Mailing Address 1 1390 ORIOLE DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1390 ORIOLE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5056
Tax Map No. section 55.00 block 6 lot 15.040
Cross Street TUTHILL ROAD EXT.
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
J '
OFFICE OF THE TOWN CLERK COW
Town of Southold 4% C'Q Application No. /7
Judith T. Terry,r y, Tow n Clerk `
� � „�pM_ � �►
Town -
Hall, 53095 Main Road s -< -$10.00 Residential
c
P. O. Box 1179 a-1 ��
$25.00 - Non-Residential
Southold, New York 11971
Telephone 01, A\*
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(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
1
Operation Permit No.
Fee $ •
DATE /6/2-- (
OWNER NAME: (1)col he -A- V3eloo < 44-/-tc ex
OWNER MAILING ADDRESS: /39-0 D 2(o /e px iv-e-
SoU // -7
OWNER PROPERTY ADDRESS: S' *Z -e
OWNER TELEPHONE NUMBER: 6S-S2)S-70
TAX MAP NO. : Section ,5"--c Block 4o Lot /,s y®
r
CROSS STREET: /O]SSe &-471.
TYPE OF SYSTEM: Septic Tank New ✓ Existing
Cesspool New I/ Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: e---J
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.)
Sig ure g. Applicant
RECEIVED BY:
Town Clerk's Office
- DATE:
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now or formerly Carl & Anthony Codan & Another