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� Town Hall, 53095 Main Road
� O � �►%N P.O. Box 1179
--�7Q( ifit `�� ►►� Southold, New York 11971
JUDITH T. TERRY 4.<••A,�� ,/#0. TELEPHONE
TOWN CLERK (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. 1071-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCNEIL, JOHN H.
Mailing Address' 1 185 WEST CREEK AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 185 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHGUE NY 11935-0000
Owner Telephone No: 516-734-6613
Tax Map No. section 103.00 block 13 lot 18.001
Cross Street OLD PASTURE ROAD
Date Of Last Pump Out 6/17/86
Issue Date: 4/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �� *R' �-
Town of Southold ..-- �' /6 7J
�� �_,. CQG� Application No.
Judith T. Terry, Town Clerk �`�'.ar1` ,,,,: i.,--4:5 li y ✓
Town Hall, 53095 Main Road a 4,= - �, Residential
O. Box 1179 u7 ' - .5A,,.z"
P. _ ; Non-Residential
Southold, New York 11971 O • ' 0 e
Telephone S..4?---%ge ''
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
i for
OPERATION PERMIT .
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ to • .
• DATE 17l/3 /d9
OWNER NAME: „Tow H. /vl c7VE1Z
OWNER MAILING ADDRESS: 1d.5 WE5 i CF EEl-- 4 vE
Ctiro/os-uE .
OWNER PROPERTY ADDRESS: ler 14/55 7- le --Ek- Avg"
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OWNER TELEPHONE NUMBER: 574 - '73L/ —6,6 /3
103'13--1,1',1
TAX MAP NO. : Section Block Lot
CROSS STREET: 0 id, ,J(e_,J, Ed,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1/ New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: Co J17 f a'6
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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Signature of Applicant
RECEIVED BY: oic?—(� y,�
iown CClerk's Tice
DATE:____________
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