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JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK O Fri % P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICERy0 Fax (516) 765-1823
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(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2015-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LETSON FRED C. & CHRISTINE
Mailing Address 1 420 THREE WATERS LANE
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 SAME
Property Address 2
City St Zip 00000-0000
Owner Telephone No. 516-323-3639
Tax Map No. section 15.00 block 6 lot 26.000
Cross Street PARK VIEW LANE
Date Of Last Pump Out 0/00/00
Issue Date: 12/03/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
' • iii i�-
OF�I,CE OF THE TOWN CLERK �FFO(� a
_ Town of Southold ' ,. r-1, CQG; Application' No ic
Judith T. Terry, Town Clerk % � y , y
Town Hall, 53095 Main Road '-"'t Vx 4 ' $10.00 - Residential
p. 0. Box 1179 cryW.': % $25.00 - Non-Residential
Southold, New York 11971 O ® '' ' .%-s
Telephone = ( Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • DATE1)6---iI a (l Q gL
OWNER NAME: -C' ( ,C. _el 5'o - �O��Z
OWNER MAILING ADDRESS: 1: C:5- ---1,;(::.&e__
/ Aii4-6...0 tietzi74_,Q.,___-
_6V_X;42,,,k* J <., // i2-.5---/ •
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OWNER PROPERTY ADDRESS: g
OWNER TELEPHONE NUMBER: .5 , - 3Z 3 3 C 3 f
TAX MAP NO. : Section / 5"-- Block G Lot Z (o
CROSS STREET:
TYPE OF, SYSTEM:- -Septic Tank -- - - New Existing
Cesspool V 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:)
Signature of Applicant
RECEIVED BY: . -
' Town Clerk's Office
DATE: