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JUDITT. TERRY ����®
H Gd Town Hall, 53095 Main Road
TOWN CLERIC P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ® T Southold, New York 11971
6) 765-13
MARRIAGE OFFICER /�`` TelephonFax e 5(516) 7651801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1668-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FICNER, WALTER
Mailing Address 1 7990 OREGON ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 7990 OREGON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6906
Tax Map No. section 950.00 block 4 lot 6.000
Cross Street DEPOT LANE
Date Of Last Pump Out 0/00/00
406400:07,6rogic..
Issue Date: 4/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i
OFR ,E OF THE TOWN CLERK \\VFU
Town of Southold �� _ - �CQ Application No.
Judith T:' Terry, Town Clerk
Town Hall, '5-3095 Main Road
� $10.00 - Residential
is
P. O. Box 1179 � 'f=Kt , $25.00 - Non-Residential
Southold, New York 119715Z' 4
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /b. 00
DATE / / 79i
7
•
OWNER NAME: ‘),16.-.210.j--
OWNER
/ j—
OWNER MAILING ADDRESS: °7 ID , - �,�� I?D
a
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: /31/1— 6 90 6
TAX MAP ,NO. : Section '95- Block 17 Lot �o
CROSS STREET: jdca "'
U TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: T „s,;, 1y 9/
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 Applicant
RECEIVED BY: Alt /170w
Town Clerk' Office
DATE: V — 7 -2 -- 9/
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