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Town Hall, 53095 Main Road,
VO O .44 P.O. Box 1179
Al 070' Southold, New York 11971
JUDITH T.TERRY - ��1i. 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. 1345-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACNISH, RICHARD AND ELIZABETH
Mailing Address 1 RD 1, 35995 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 35995 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6052
Tax Map No. section 97.00 block 1 lot 21 .000
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/45
Issue Date: 12/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
9
OFFICE OF THE TOWN CLERK •
Town of Southold Q CSG• Application No. / 35/
Judith T. Terry, Town Clerk IV ter. ..
Town Hall, 53095 Main Road �� -� ` $10.00 - Residential
g. ASF �
P. O. Box 1179 '` i'4 �� $25.00 - Non-Residential
uu-
Southold, New York 11971 O
Telephone 7®4 y I%
(516)
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No./c34'1-5J
Fee $ •
DATE ig/7'6
OWNER NAME: e Il`a,Cc. 4 ,E b 7-h M a •
OWNER MAILING ADDRESS: 62d �,5���' ;1V,\e =25—
Cicc'MA ®if Cp F /v.
OWNER PROPERTY ADDRESS: ./11-0')/,
OWNER TELEPHONE NUMBER: 6'76- ds-,7
TAX MAP NO. : Section 7 7 Block / Lot c /
CROSS STREET: 60ZId�
642F,5-5 E 7 2
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: • ` 9
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.)
atjeL4- e
Si nature of Applicant
RECEIVED BY: A` // ' C
Town Clerk's Office
DATE: /A -/9 - ��
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