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OFFICE OF THE TOWN CLERK cOFO(.fr�
Town of Southold �o L'Q ' Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c * "r ” Residential
P. 0. Box 1179CS) ` Non-Residential
Southold, New York 11971 "r- NQS
Telephone : ./
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ �✓,
DATE r
OWNER NAME:
OWNER MAILING ADDRESS: _" -
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 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.)
Signature of Applicant
RECEIVED BYeAl _._
R own v erk's Of ce
DATE:
SEP 3o 987
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OFFICE OF THE TOWN CLERK 6 c.�FFULire,
Town of Southold (flj
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Judith T. Terry, Town Clerk •
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Town Hall, 53095 Main Road
P. O. Box 1179 i crr r
Southold, New York 11971 t
Telephone 40%
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. NR 52 Residential
Non-Residential X
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Robert Brown - Sunrise Coach Lines
OWNER MAILING ADDRESS: P.O. Box R
Greenport, New York 11944
OWNER PROPERTY ADDRESS: Route 25
Greenport, New York
OWNER TELEPHONE NUMBER: 516-477-1200
TAX MAP NO. : Section 45 Block 6 Lot 6
CROSS STREET: Moores Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential X
DATE OF PREVIOUS PUMP-OUT: Unknown
cortake
Judith T. rry
Southold Town Clerk
DATE: September 30, 1987
(TOWN SEAL)
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