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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; Southold, New York 11971
Mi Fax (516) 765-1823
MARRIAGE OFFICER
���i Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1790-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LYNN, GRANT C/O STEVEN LYNN
Mailing Address 1 148 VALENTINE AVENUE
Mailing Address 2
City St Zip SPARKILL NY 10976-0000
Property Address 1 550 EAST ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 914-365-2178
Tax Map No. section 110.00 block 7 lot 18.004
Cross Street PEQUASH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'COFO(ir
Town of Southold �� CQ ' , Application No. / 2
Judith T. Terry, Town Clerk . r 4
Town Hall, 53095 "Main Road $10.00 - Residential
P. O. Box 1179 tri ,. $25.00 - Non-Residential
Southold, New York 11971 O "-®a *�
Telephone ®j N�® '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,00
DATE 7/25/ / •
OWNER NAME: G RANT L'//lip c/e3 STEVEN L-W/7/
OWNER MAILING ADDRESS: //,, V A-L NY \/E, /cu1 5(10A-g fc) L ,
Nty' t 06(16
OWNER PROPERTY ADDRESS : 5 O EA5T p4 £ UTC k Oc Ur
.y, 1g35
OWNER TELEPHONE NUMBER: C� (td--- 3 (:,5 — 2 r?
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF" SYSTEM: =Septic -Tank- L7 New Existing
Cesspool 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 /Applicant
RECEIVED_- BY:
Town Clerk's Office -
DATE:
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