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JUDITH T. TERRY .! Town Hall, 53095 Main Road
TOWN CLERK O
P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS 1 :' Southold, New York 11971
MARRIAGE OFFICER O �,��� Fax (516) 765-1823
�i�. Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 124-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner SPATES, DONALD
Mailing Address 1 JOCKEY CREEK HARDWARE, INC.
Mailing Address 2 BOX 786
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. 516-765-2122
Tax Map No. section 70.00 block 5 lot 6.002
Cross Street JOCKEY CREEK DRIVE
Date Of Last Pump Out 0/00/84
Issue Date: 11/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK SOFOC,r =
Town of Southold �� CQj• Application No.lgJ/�' wei
Judith T. Terry, Town Clerk rw 2 4
Town Hall, 53095 Main Road < $10.00 - Residential
P. O. Box 1179 trix > z $25.00 - Non-Residential i----
Southold,
Southold, New York 11971 O -kz$
Telephone 0 ~
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1 3 — /
OWNER NAME; 1)0 Nest-
OWNER MAILING ADDRESS: goy- -7 06
-- - OWNER PROPERTY ADDRESS: /�:� b _
c cs, Bs•-"t/ L l/o'k Nei r L 6 117
OWNER TELEPHONE NUMBER: —1 6
TAX MAP NO. : Section Block Lot
CROSS STREET: .r ®v �� C- ' e L ✓�
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.)
Si ature of Appli writ
RECEIVED BY:
Town Clerk's Office
DATE:
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