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JUDITH T. TERRY � ��1 o '* Town Hall, 53095 Main Road
TOWN CLERK • Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
cm, r� Southold, New York 11971
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. 1656-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MARTIN, JOHN F. AND LINDA M.
Mailing Address 1 P. O. BOX 680
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 815 OLD SHIPYARD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3120
Tax Map No. section 64.00 block 5 lot 19.000
Cross Street LANDON LANE
Date Of Last Pump Out 0/00/78
Issue Date: 11/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE •0F THE TOWN CLERK .c.31Fair
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Town of Southold � : _ Application No.
Judith T. Terry, Town Clerk . y
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Town Hall, 53095 Main Road � � : .; $10.00 - Residential
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P. O. Box 1179 E 1:
: $25.00 - Non-Residential
Southold, New York 11971
Telephone y �� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ Aar
DATE
OWNER NAME: __. 01-\1(\--V 41 1 nAck...
OWNER MAILING ADDRESS: P o SaD v., G-s o
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OWNER PROPERTY ADDRESS: (S D Shj Qkafi c L
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OWNER TELEPHONE NUMBER: nco S -3
TAX MAP NO. : Section 0(49L.I ,DD Block 05, 00 Lot o f q , DUd
CROSS STREET: La-\ Ao L yt ,
TYPE OF SYSTEM: Septic Tank New Existing �(
Cesspool A New Existing t/<
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: l 9‘2P ?
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.)
Sign- P re of Apt1,i ' nt
RECEIVED BY:
Town Clerk's Office
DATE:
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PABST BREWING COMPANY
917 W.JUNEAU AVENUE, MILWAUKEE, WISCONSIN 53201 (414) 347-7300 TWX#910-262-1111
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