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JUDITH T. TERRY trZ . 1. :r4 Town Hall, 53095 Main Road
TOWN CLERK '; Ci4gP.O. Box 1179
� fi r Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER G tom Fax (516) 765-1823
Lth 4.ot Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 119-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner PORT OF EGYPT ENTERPRISES INC.
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2445
Tax Map No. section 56.00 block 6 lot 6.001
Cross Street BAY HOME ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/11/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cvFFObr '�-
Town of Southold X. C'� Application No.///Klt
Judith T. Terry, Town Clerk a ..) $10.00 - Residential
Town Hall, 53095 Main Roada .
p. O. Box 1179 En4 �� $25.00 - Non-Residential
Southold, New York 11971 O �
Telephone �%
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3- q
OWNER NAME: PO/C( or I✓ZoYO7 / /• L •
OWNER MAILING ADDRESS: al t 6-40
r
/ f I`q '?
OWNER PROPERTY ADDRESS: ,!OWNER TELEPHONE NUMBER: 76S- - 02 (/c(J
TAX MAP NO. : Section Block Lot C-r
CROSS STREET: (000' tf* OP 6 , >11b''`,e
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.)
./AfAMW
/ / c
wSig ature of Applicant
RECEIVED BY: Ali
79 /;
Town Clerk's ffice
DATE: 3/X