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JUDITH T. TERRYc,, ,4 TTown Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER V, Fax (516) 765-1823
® 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. 1907-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCCORMICK, JOHN P. AND EDITH M
Mailing Address 1 P. O. BOX 732
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 565 BARLEY LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1828
Tax Map No. section 59.00 block 4 lot 5.010
Cross Street GREENFIELDS LANE
Date Of Last Pump Out 0/00/00
Issue Date: _1 /92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF THE TOWN CLERK �c0FO(,ir
Town of Southold - CQ ' Application No. 19° ?
Judith T. Terry, Town Clerk , 3
Town Hall, 53095 Main Road { C $10.00 - Residential
P. O. Box 1179 cr3 � fS?g' :' $25.00 - Non-Residential
Southold, New York 11971 ® � �o���•,
Telephone = 1 Y►
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /9O 7
Fee $ ld.
DATE --/7/211Y).
e
OWNER NAME: �JS)%Q j 2!/ - /' 02
OWNER MAILING ADDRESS: , ;? 0/9-/z Zgy 61'
jr/hp Lo, /0-1 /1”/
OWNER PROPERTY ADDRESS: SCS J- L /4
1 aL,°. 1)-y Jl971
OWNER TELEPHONE NUMBER: S'/4) 744 a r _
TAX MAP NO. : Section 9 Block 4/ Lot j /0
CROSS STREET: 649,G N r1 Lrib 5 A,0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential .4 Non-Residential
DATE OF PREVIOUS PUMP-OUT: I
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.)
tee/ /f61-'2#-V6
Signature of Applicant
RECEIVED BY: At I
Town Clerk's Office
DATE: cLd/�j'l� -
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• NOTE ■=MONUMENT SOUTHOLD AMERICAN TITLEINSURANOE CO.
SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK TOWN O. SOUTHOLD SAVINW BANR
OF SUFFOLK=wry oil Nom 10,1912 AS FILE NO.6313. SOUTH OLD
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