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JUDITH T. TERRY z - Town Hall, 53095 Main Road
TOWN CLERK '1% P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS ;
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aFFICE OF THE TOWN CLERK .���F�(i. •
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Town of Southold � �Q Application No. / v6
Judith T. Terry, Town Clerk .`� '
Town Hall, 53095 Main Road } $10.00 - Residential
P. O. Box 1179 � r h�i �` $25.00 - Non-Residential AV
Southold, New York 11971 O ® •�`
Telephone .0`~ ge�
(516) 765-1801
TOWN OF SOUTHOLD
REMO SOUTHOLD WASTEWATER DISPOSAL DISTRICT
JAN 5
-1
APPLICATION
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Town Clatt
for _.
OPERATION PERMIT,
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ �7
DATE la` 0 (
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OWNER NAME: ! &"ä gei".l'
OWNER MAILING ADDRESS: 1? I.. 3
4 ,
-.. A.._CMNER- PROPBI;dY ---- -243-4420
thre rtAt 5.
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OWNER' TELEPHONE NUMBER: If ec/40/
TAX MAP NO. : Section / OBlock 6 Lot 1
CROSS STREET: ! Li (91 w /7. - '
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
•
Residential Non-Residential
X
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.)
Signature of Appl'
RECEIVED BY: - -
Town Clerk's Office
DATE:
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