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nm 4 Town Hall, 53095 Main Road
,s. VB ' .$ P.O. Box 1179
��® �� Southold, New York 11971
JUDITH T.TERRY r ®l ',01 TELEPHONE
TOWN CLERK , "•
!o (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. 856-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner LEWIS, GRACE R.
Mailing Address 1 BOX 877
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 PRIVATE ROAD OFF MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3416
Tax Map No. section 66. 00 block 3 lot 15. 000
Cross Street LAUREL LANE
Date Of Last Pump Out 0/00/84
Issue Date: 9/23/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.
OFFICE OF THE TOWN CLERK c:1\FFO(,r`;-
Town of Southold . . � - Application No.
Judith T. Terry, Town Clerk �� ^ �. y
_~ =fir= �G 1 Residential
Town Hall, 53095 Main Road a .
P. O. Box 1179 u-3M , ;Wa' h�i
� a �,� � Non-Residential
Southold, New York 11971 O ® •1
Telephone S())//id''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE G�j
2-'Z_Af�
OWNER NAME: 6fy Cg 72, ��fJ
OWNER MAILING ADDRESS:
c o eziD /0 5 t 1 7/
OWNER PROPERTY ADDRESS: " � C SO `-[--� ,
72a2 itta/W/7-1
OWNER TELEPHONE NUMBER: )6“7---- 34C
TAX MAP NO. : Section 6.6" Block 3 Lot tit
CROSS STREET: /,r (C.{-c
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing >(--
Residential 1'" Non-Residential
DATE OF PREVIOUS PUMP-OUT: z. __j cjG4/14 146-4 Z
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.)
Sick .lure-of Applica t
GLS
RECEIVED BY:
Town Clerk's Office
DATE: