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WTown Hall, 53095 Main Road
P.O. Box 1179
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',� Southold, New York 11971
JUDITH T.TERRY %.�,ir/ oFAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1000-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LATHAM, EDWARD
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2593
Tax Map No. section 19.00 block 1 lot 7.002
Cross Street NARROW RIVER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK \WHO(
Town of Southold �� CQ ' Application No.I O
Judith T. Terry, Town Clerk t ke :`='
Town Hall, 53095 Main Road 4,1: Residential .i
'` ' Non-Residential
P. O. Box 1179 cn �: W`, ?x
Southold, New York 11971 � = 0 •,
Telephone o,( , � �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ D
DATE Pa, / /f
OWNER NAME: Y1A —
OWNER MAILING ADDRESS: MA/ +� ��
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 2 2, 3 ^ 2.5-9
TAX MAP NO. : Section / Block Lot f 7 3 kef I
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X_
Residential $ Non-Residential
DATE OF PREVIOUS PUMP-OUT: - �5 u,t 7`' /S &F'
CJ �
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:
own Clerk's Offi
DATE: (--/-e--b- 0,4.1.,\ 62 f /. .‘(r/c.
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