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$ Town Hall, 53095 Main Road
1, ®� ,,` P.O. Box 1179
I • '/!1 Southold, New York 11971
JUDITH T.TERRY �,,,,,v 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. 1527-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCSHERRY, JOANNE B.
Mailing Address 1 P. O. BOX 600
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 660 BAYBERRY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6999
Tax Map No. section 118.00 block 1 lot 13.001
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/82
Issue Date: 9/19/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ic�VFFO(,rCC'�'-
Town of Southold � = /J-02-7
� � G Application- No.
Judith T. Terry, Town "Clerk1 1�f $10.00 - Residential
Town Hall, 53095 Main Road �� !,44'6I
P. O. Box 1179 u-3 `'. x hzi
$25.00 - Non-Residential
Southold, New York 11971
•
Telephone ��
(516) 765-18011.4
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /d X0
•
DATE f— /7— Yd
OWNER NAME: ,To itj , l r1/ e- /)7 CS e /- 1f •
OWNER MAILING ADDRESS: -0 C) cv Cp d
C L1 / A O j ' y/ //9.3s -
OWNER PROPERTY ADDRESS: G c o r� R y Nf^y ,e4
C c Ao yaf ,tJy // 93s -
OWNER TELEPHONE NUMBER: 7331 e 9 y 9
TAX MAP NO. : Section / / i/ Block / Lot / a
CROSS STREET: ioe- dye 11 .) -e — kJ id oic X/51-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
- DATE OF PREVIOUS PUMP-OUT: =-- 1?6)G2.
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locale building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
. /5.-
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: