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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : ® 11/1 t
Southold, New York 11971
Fax 6) 765-13
MARRIAGE OFFICER I Telephone (5 6 7651801
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OFFICE
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 118-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner SORTERS INC. FOR NETED OF
Mailing Address 1 AMERICA LTD.
Mailing Address 2 73 NORTH OCEAN AVENUE
City St Zip PATCHOGUE NY 11772-0000
Property Address 1 2835 SHIPYARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2254
Tax Map No. section 38.00 block 7 lot 7.001
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 1/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOFGL4
Town of Southold \N4' f• . CQ Application No. 74-
Judith T. Terry, Town Clerk \ r,Y`
Town Hall, 53095 Main Road t - $10.00 -.Residential
p. O. Box 1179
cry $25.00 - Non-Residential
Southold, New York 11971 O ® ; ` *-$
Telephone Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
- APPL�CATION for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •2S
DATEZ/257.
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'OWNER NAME: S'CIZTL S )417 ir-ri)L/ 447179 z AmL7Ll 67--v •
OWNER MAILING ADDRESS: 73 Al dGaoti 4l/
PX-7-Nd 4-2/6-}
/ } D7 /t772-
OWNER
)772 OWNER PROPERTY ADDRESS: 2 .35 5Al)P fM1i LA.
s1�i24dd ruy I> q37
OWNER TELEPHONE NUMBER: 5/6 4-72" 22.14
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TAX MAP NO. : Section Block Lot
CROSS STREET: A ZS
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: dNklt/
/1.
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.)
Signatur- of Applicant
r
EDWARD A.STIL°:.•-ADEN,J .
RECEIVED BY:
Town Clerk's Office
DATE: