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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® vi tit Southold,
Box 1179
REGISTRAR OF VITAL STATISTICS `. Southold, New York 11971
MARRIAGE OFFICER ��� Fax (516) 765-1823
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it" 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. 1812-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LINDSAY, WILLIAM JR.
Mailing Address 1 2695 COX NECK ROAD
Mailing Address 2 •
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2695 COX NECK ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4863
Tax Map No. section 113.00 block 7 lot 2.006
Cross Street BERGEN AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 11/21/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK • \\FFU
Town of Southold �� �Q� Application No. fg./-
Judith T. Terry, Town Clerk t,. 3 y
I10.00 - Residential
Town Hall, 53095 Main Road o $
- P. Oa ,Box 1179 cry ' rc #� $25.00 - Non-Residential
Southold, New York 11971 O ® =47-;#,/Telephone ®j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /p
DATE -'724-ti • % 5-7 / ?j
OWNER NAME: ,LO "4--"3-V
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OWNER MAILING ADDRESS: c.: ��'
OWNER PROPERTY ADDRESS: fy�„�R Cameo" Q,
OWNER TELEPHONE NUMBER: 02, 9,f— 14d'(02
TAX MAP NO. : Section / / 3 Block 7 Lot <,?, (o
CROSS STREET: 2 4.-rq-d -eft) �(f�
TYPE OF-SYSTEM: Septic Tank 1/ New Existing
Cesspool i/ 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.)
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Signatu re of Ap 'carXt/
RECEIVED BY: rY CL��
Town Clerk's Office
DATE: RMCO1W -
NOV 21 MI
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Town Clerk Southold
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