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Town Hall, 53- 4 095 Main Road
cP.O. Box 1179
__ ®� � Southold, New York 11971
JUDITH T.TERRY y�ii:��� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 84-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner SCHNEIDER, LEO
Mailing Address 1 840 TOWN HARBOR LANE
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. 516-765-5546
Tax Map No. section 61 .00 block 1 lot 19.000
Cross Street BECKWITH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/11/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,, • II.0.
OFFICE OF THE TOWN CLERK
Town of Southold 0�� „; CQG' , Application No. /o
Judith T. Terry, Town Clerkt 't
>{ .•G Residential
Town Hall, 53095 Main Road 1='
P. O. Box 1179 cr3_ �> F •%-$� Non-Residential
Southold, New York 11971 O414:14.5%- ��
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ a'e
DATE
OWNER NAME: L-2O
OWNER MAILING ADDRESS:
,c4-e-&0/4/ A2-7- 7/ 9 7 I
OWNER PROPERTY ADDRESS : S ' ' t-jl , ,e-4/
OWNER TELEPHONE NUMBER: 76 -LT-1 -6
TAX MAP NO. : Section 6 / Block / Lot
CROSS STREET: .Q,,e.a, Au
TYPE OF SYSTEM: Septic Tank v New Existing 9
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.)
Si ature of Applicant
RECEIVED BY: dV � edy
_„ �� Town erk's Office
•DATE: �l���® i x®09
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