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Town Hall, 53095 Main Road
am® ®viii' P.O. Box 1179
NA ED
_ � " Southold, New York 11971
JUDITH T.TERRYe. i,i! FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1179-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FEINBERG, RANDALL
Mailing Address 1 P. O. BOX 186
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 111 SKUNK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-9328
Tax Map No. section 97.00 block 8 lot 10.000
Cross Street LESLIE'S ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK r �c5�FFO(,1r�'
Town of Southold �® CQG' Application No. // 7
Judith T. Terry, Town Clerk ` ai `
Town Hall, 53095 Main Road ~ 0,..--
w "` 'xj $10.00 - Residential
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P. O. Box 1179 V. ,}S�i'� x ��•,3,�,�r�•KK�` % $25.00 - Non-Residential
Southold, New York 11971 4 � " 7 0 ,.S
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Z)
DATE & -013. - 'n
OWNER NAME: P1 •
. C
OWNER MAILING ADDRESS: k 0 fj c. --2(.., 1 Vc,
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OWNER PROPERTY ADDRESS: � �
OWNER TELEPHONE NUMBER: 9 g -Cr'g-0
j TAX MAP NO. : Section 17 Block 'g-
Lot TO
CROSS STREET: e,,,, /.sz....D le-C-6LC-9- N.
O
A.
TYPE OF SYSTEM: Septic Tank V/ New Existing 7
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.) �\
�Lo c-o moo` 1 �7 q,.�a -�,A - 6 . kr-c,w- C G)o v e -r ° k
S wa ry ''w� ^-f2-1\) 0 ' Taal) c'-- Pignature of Applicar t
01
4 � o u-S R.
>(,
£ S
RECEIVED BY: �``�. _
I-sorMigitrk's Office
DATE: JUUN 3 0 '9b4