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Town Hall, 53095 Main Road
`, P.O. Box 1179
=_�® ° ���' Southold, New York 11971
JUDITH T.TERRY -®1 1°. TELEPHONE
TOWN CLERK "'0'�iiiiii° (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 820-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LEVIN, JACK J.
Mailing Address 1 BOX 68
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 PEBBLE BEACH APARTMENTS
Property Address 2 COUNTY RT 48
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1910
Tax Map No. section 44.00 block 2 lot 3 .000
Cross Street ALBERTSON LANE/CHAPEL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 9/08/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK 'cOMA,�'-
Town of Southold � C� : Application No.
Judith T. Terry, Town Clerk 7�c
Town Hall, 53095 Main Road o 5 :< Residential
P. 0. Box 1179 1: `� o ', z Non-Residential
Southold, New York 11971 O ® x
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ IpT
•
DATE 3d1 7 q
OWNER NAME: V -v
OWNER MAILING ADDRESS oy. s(
OWNER PROPERTY AR-ESS: _o 0 t`,"V
OWNER Uu
TELEPHONE NUMBER: S I b ^ )
TAX MAP NO. : Section Block Lot
CROSS STREET:
_TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing L�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: His Iv Qv '.:L�� ��,�, u e \ e.4p
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.)
Signatur of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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