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JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS _‘ti%‘V. Southold, New York 11971
MARRIAGE OFFICER yQ 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. 3145-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCGLYNN, PAUL
Mailing Address 1 BOX 206
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 NORTH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2037
Tax Map No. section 74.00 block 4 lot 15.000
Cross Street PECONIC LANE
Date Of Last Pump Out 0/00/00
Issue Date: 11/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c3VFFO(,t-
Town of Southold z� CQG' , Application No.3//s'
Judith T. Terry, Town Clerk � ....b ;:r�i- %'_,•
Town Hall, 53095 Main Road ~ 0` 1.,� ), $10.00 - Residential
P. O. Box 1179 Yl ��; $25.00 - Non-Residential
Southold, New- York 11971 Oho'a 0‘C"- ••..
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Telephone .� '�1 ..
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
. DATE 22/J`C eU /d) /`?
OWNER NAME: , c.9 I ti& __ l l
7 0/4
OWNER MAILING ADDRESS: af, ,'4
Pew ,u 1L .0r //Q-C1'
OWNER PROPERTY ADDRESS: 0 r14,
ec o ith-c, id_ 'i' ii '
OWNER TELEPHONE NUMBER: 1.4 r -0,0 3 —2
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TAX MAP NO. : Section pi--'1—/.5----Block Lot
CROSS STREET: l ec aall, L —7 e--
T,YPE_70,E;SY;5TEM:-----Septic Tank-". . -----`New Existing
Cesspool I/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /10•- -13
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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ignature f Applicant
Town Clerk's Office
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