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Town Hall, 53095 Main Road
rte® &=, .4 P.O. Box 1179
P� �!r, Southold, New York 11971
JUDITH T.TERRY „ i/yr'��� 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. 1119-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FELDIS.. DOROTHY ANNA
Mailing Address 1 1611 WALES AVENUE
Mailing Address 2
City St Zip BALDWIN NY 11510-0000
Property Address 1 18305 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-546-4734
Tax Map No. section 51 .00 block 1 lot 10.000
Cross Street MT. BEULAH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/23/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
J i r
OFFICE OF THE TOWN CLERK ..c1FO(�• l
Town of Southold �� CQ�'� Application No. ///J
Judith T. Terry, Town Clerk � yF moi Residential
Town Hall, 53095 Main Road
P. O. Box 1179 "
xt1 ?�ti�`' Non-Residential
Southold, New York 11971 ® ®' ,. ��•`
Telephone _ ( It 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
PAY 2 3 Meg
OPERAT ION PERMIT
{ t'nn w,�1;jE9Ctib
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D 00
DATE 3/v7/1(9.
OWNER NAME: ,D o y-t, L �y In to a, ' t At.
S
OWNER MAILING ADDRESS: 61b 41
B1t 11 ,1 US-
OWNER PROPERTY ADDRESS: i 8 3 a 5 SO wAAA. v t e Po/f.,
Ci6tt$ \nb1, 1\�ri Ltgl
OWNER TELEPHONE NUMBER: ‘..5") 654-4 )4134- 423
TAX MAP NO. : Section 5/ Block / ' Lot ./0
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing '✓
Residential i/ 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.)
A/14)-?hiSigne of Applicant
RECEIVED BY:
mClerk's Office
DATE: MY 2,3 1984
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