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t k�' .,, ;;= ��' a Town Hall, 53095 Main Road
.�® - � ��� P.O. Box 1179
= Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 98-N Residential Non-Residential X
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CELIC, ROBERT A.
Mailing Address 1 P. O. BOX 1247
Mailing Address 2
City St Zip MATTTIUCK NY 11952-0000
Property Address 1 ROUTE 25
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-298-8000
Tax Map No. section 45.00 block 6 lot 3.000
Cross Street SILVERMERE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�VFFO(,r '-
Town of Southold � ,_. C'� ' Application, No4/i 91�
Judith T. Terry, Town Clerk `
: fr .G
Town Hall, 53095 Main Road � ��� �:' 'i;{�. $10.00 - Residential
P. O. Box 1179 crys` -'is' i $25.00 - Non-Residential
Southold, New York 11971 Off`� �••`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ J (IU
DATE D ��
OWNER NAME: De271-
OWNER MAILING ADDRESS: 9D , 44 /2V'7
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--- -OWNER-PROPERTY ADDRESS: ,02�.�-
GfIrde// //Pel
OWNER TELEPHONE NUMBER: p2p ---8Q7c)
TAX MAP NO. : Section O�,S Block Lot �3
CROSS STREET: ] Oc �S'�G�/G�2il/6Z E7o��D
TYPE OF SYSTEM: Septic-Tank New Existing
Cesspool New Existing )‹. (.13 •)
Residential Non-Residential >e—
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.)
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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