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JUDITH
JUDITH T. TERRY ,; _ < Town Hall, 53095 Main Road
TOWN CLERK ® gyp �' P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER '�® � Fax (516) 765-1823
Telephone (516) 765-1801
TOM' $1>>�-4 Attie Il.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1631-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LAYBOURNE, ELLEN
Mailing Address 1 15 MIDDLETON ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 15 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0196
Tax Map No. section 40.00 block 5 lot 5.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 2/27/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE'OF TH5. TOWN CLERK cvFFOL-�'-
Town of Southold o CQ Application No. /t 3
Judith T. Terry, Town Clerk r '�. "
Town Hall, 53095 Main Road ,{ $10.00 - Residential
p. O. Box 1179 v' V` z $25.00 - Non-Residential
Southold, New York 11971 O ® t
Telephone of
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATEr.-2 — j...0 --q/
OWNER NAME: EL /v 1i1-1-' d dkid '
•
OWNER MAILING ADDRESS: J5 ,/ b() Le- a /O
Pa -if toy lifvy
OWNER PROPERTY ADDRESS : Pc-IA CZ:-
OWNER
OWNER TELEPHONE NUMBER: 7?f 6 /
TAX MAP NO. : Section CIO Block 5- Lot
CROSS STREET: Roo 7 rm, Li
TYPE OF SYSTEM: Septic Tank 1 New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Ueeryti &,,Signature or • pplicant
RECEIVED BYQ Et [U) i7
Town Clerk's Office
DATE: Fro8 ����
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