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OFFICE OF THE TOWN CLERK • cOf el./(`,O
Town of Southold � lj
Judith T. Terry, Town Clerk <�
Town Hall, 53095 Main Road '� 'mac
P. O. Box 1179 � '. ��•
Southold, New York 11971 .77C-1:7,&,71P.-:' �- •
Telephone ------"1„0
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 293 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Vincent P. and Robin V. Martin
OWNER MAILING ADDRESS: Box 47
New Suffolk. New York 11956
OWNER PROPERTY ADDRESS: 860 Fanning Road
New Suffolk, New York
OWNER TELEPHONE NUMBER: 516-734-5298
TAX MAP NO. : Section 117 Block 6 Lot 35
CROSS STREET: New Suffolk Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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Judith T. Terre
Southold Town Clerk
DATE: May 4, 1987
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(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO
Town of Southold �� CQ Application No. 67_9/.3Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road 7 Residential
P. O. Box 1179 ' Non-Residential
Southold, New York 11971 0���`
Telephone �j `ib
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION ,PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE e.-57—
OWNER
- —OWNER NAME: V/f��°ei/ ? 8.6//Y1 - � /( /4)
OWNER MAILING ADDRESS: 42% 7
/'amu/ V FU// /v•7 //9s 7
OWNER PROPERTY ADDRESS: D 7a/)/t)///6"P- ,&'
Ai $ f[ //
OWNER TELEPHONE NUMBER: 5.-2 9,
TAX MAP NO. : Section // '� Block Lot 3
CROSS STREET:
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
"es-4,Z
Signature of Applicant
RECEIVED BY: a ,-
R ELL, viVown erk's O ice
DATE: WI AY 0 4 1987
Town Clerk Southold
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