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Town Hall, 53095 Main Road
�� O P.O. Box 1179
-__ TED own Southold, NewYork 11971
JUDITH T.TERRY = �� FAX(516)765-1823
���� TELEPHONE(516)765-1801
TOWN CLERK
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. 1250-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACDONALD, JAYNE
Mailing Address 1 P. O. BOX 58
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 315 HORTON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5129
Tax Map No. section 104.00 block 2 lot 2.000
Cross Street PINE TREE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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4'S '.I •
OFFICE OF THE TOWN CLERK COMA'- -
Town of Southold Qlo '- Application No. �as�
Judith T. Terry, Town Clerk r e.c � $10.00 - Residential
Town Hall, 53095 Main Road 'L'~F
P. O. Box 1179 L Qm '`x`' " i •
' • $25.00 - Non-Residential
Southold, New York 11971 Q "® ��•
Telephone :?( `��® ►�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for - •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE (' ) I M
OWNER NAME: G� N P\K '
OWNER MAILING ADDRESS: t ' (, (..c3)04
Cr
OWNER PROPERTY ADDRESS: 3 ` RC) ci `,�1,0-n
OWNER TELEPHONE NUMBER: 1 (o 73 -(S12/9
TAX MAP NO. : Section )-09 Block a Lot
CROSS STREET: , Ibh AJ .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 41 "1:7-87
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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