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11
JUDITH T. TERRY m, Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ` ® w14 Southold New York 11971
REGISTRAR OF VITAL STATISTICS "Iel '4%
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MARRIAGE OFFICER ` ' yet•s. �� Fax (516) 765-1823
a �s�� 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. 1730-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LEARY, BARBARA A.
Mailing Address 1 220 MADISON AVENUE
Mailing Address 2
City St Zip NEW YORK CITY NY 10016-0000
Property Address 1 PECONIC BAY BOULEVARD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-9471
Tax Map No. section 145.00 block 2 lot 8.000
Cross Street LAUREL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 7/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �5OF0(,(,'-
Town of Southold CQG', Application No. /x36
Judith T. Terry, Town Clerk : •
Town Hall, 53095 Main Road 533�� ' - y{ -4. ) $10.00 - Residential ,/,/p. O. Box 1179 } T'-:M ` $25.00 - Non-Residential
Southold, New York 11971 O ®. ‘r,
Telephone - /
pyo _-- - ���
Telephone _ .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 6 ,®o.
DATE •• 4 43 fcm/
OWNER NAME: .fa)Q8/112-4 dff, 1, 4
OWNER MAILING ADDRESS: oda.® 44bl56h/ i/
OWNER PROPERTY ADDRESS: 14=-0_0AI1 (l' 4 ALVD .
t--1 LiP EL (
OWNER TELEPHONE NUMBER: 4p- '4 7
TAX MAP NO. : Section ' /14.6.- Block 2 Lot 3
CROSS STREET: i 4VR - LmiC
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool 1 / New Existing �✓
Residential l/ Non-Residential ;
DATE OF PREVIOUS PUMP-OUT: N-L re- R....„,, (&u<JY C0�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.)
AO
.44
A.if -rutg 4, ----4um
Signature of Applicant
RECEIVED BY:
Town ale k's ffice
DATE: 7A2-V,/ C='., iv