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A‘.441 Town Hall, 53095 Main Road
P.O. Box 1179
_ � ���� Southold, New York 11971
JUDITH T.TERRY - ®d ' l�� TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR 01•VITAL S CATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 854-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner LE CREN, DESIRE
Mailing Address 1 94-26 CORONA AVENUE
Mailing Address 2
City St Zip ELMHURST NY 11373-0000
/ Property Address 1 1160 BUNGALOW LANE
oY Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 718-592-4481
Tax Map No. section 123 . 00 block 2 lot 16 . 000
Cross Street CENTER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 9/22/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
' • •7g
OFFICE OF THE TOWN CLERK �FFu1,e-'-
Town of Southold � `� Application No. 87:5
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road °u z :� 1 Residential
P. O. Box 1179 cry x- moi ; Non-Residential
Southold, New York 11971 O '®, O •�`�
Telephone :(ii `W
(516) 765-1801
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVE®
i�t' �,1.
APPLICATION
S . r
lown
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
. DATE C4r
` 9 r
OWNER NAME: - e e„ R Ar c7,
OWNER MAILING ADDRESS: (� (° p R., 1,1 pi
1/11/Y) P.) I)-1,A Ar y s
OWNER PROPERTY ADDRESS:______Ln",,,� �� (W`) (� Deto
kz),z ,U--,L1,11_ 'a 9
OWNER TELEPHONE NUMBER: I ) 19, • � 4_,, ( _C 7"T Y,6°'
TAX MAP NO. : Section 1 2 ,`; Block Lot I l�
CROSS STREET: C' 'NLEe¢/1.0 Ca.J211-
TYPE OF SYSTEM: Septic Tank New Existing Fa/
Cesspool New Existing 6/
Residential �z' Non-Residential
DATE OF PREVIOUS PUMP-OUT: Rr u, P.)/ A _
LOCATION MAP: Must be attached hereto before permit may bssued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
e
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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