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,;• Town Hall, 53095 Main Road Vri%
VOA, r." P.O. Box 1179
�r ®� 1�®! � Southold, New York 11971
JUDITH T.TERRY +%'....z10''00, FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1445-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCIVER, JOHN
Mailing Address 1 2570 CEDAR AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2570 CEDAR AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5615
Tax Map No. section 77.00 block 2 lot 13.000
Cross Street OAK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • ♦oc0Fp `;- _ - �S
Town of Southold A =s OG Application No. l
Judith T. Terry, Town Clerk T ` �' $10.00 - Residential V
Town Hall, 53095 Main Road
P. O. Box 1179 v' '45,1k.#
xi z $25.00 - Non-Residential
Southold, New York 11971 • Off`® t`#'` 0 �$
Telephone ' 4j '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ AO,"
DATE 00'o
OWNER NAME: J O/V'V Al` Vel
OWNER MAILING ADDRESS: 2 5 7o C9,? ,9V1 - Soy T4 oID M: ', //jj/
OWNER PROPERTY ADDRESS: S /1"lE
OWNER TELEPHONE NUMBER: 7d S- 5"6/�"'
TAX MAP NO. : Section '7 7. Block 2 Lot - /3
CROSS STREET: 0,9K ,4 va
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t/ New Existing
Residential V- Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3/23/90
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.)
Mc
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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