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JUDITH T. TERRY �' Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS t.
MARRIAGE OFFICER Fax (516) 765-1823
��• Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1636-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACLEOD, DONALD J. AND BRIGID
Mailing Address 1 430 WEST CREEK AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 430 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6635
Tax Map No. section 103.00 block 13 lot 3.000
Cross Street OLD PASTURE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/06/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OP., THE TOWN CLERK _
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‘ Town of Southold : ,OA•.),4,. %)�t • Application No. /C34
Judith T. Terry, Town Clerk . • f •
Town Hall, 53095 Main Road ~ 't�.. -< $10.00 - Residential
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P. O. Box 1179 ,� ., ��% $25.00 - Non-Residential
VC Southold, New York 11971 O 61.47 '?"0'�`
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Telephone `A
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK CESSPOOL
Operation Permit No.
Fee_ $ /0t,
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DATE / Pr 5iY /
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OWNER NAME: �/1)/JL.0 J pe/ /i7 /A.c. 'Z
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OWNER MAILING ADDRESS: .1, r.-
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OWNER PROPERTY ADDRESS: .C,/, Z
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OWNER TELEPHONE NUMBER: 7 / ' 23.9- — ‘ :3 6
TAX MAP NO. : Section / S Block /3 Lot
CROSS STREET: I ;, ----"- /0c 0 r-0.4-,1) 75:15f_57-0/7- 1-09-
TYPE
fV/7TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7 ET 2?/ 20
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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' 'VS ure of Applicant
RECEIVED BY: 4 a &- ) -
o ni/Clerk's Office
DATE: w, 0 6 19P1
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