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Town Hall, 53095 Main Road
-_� ' �� P.O. Box 1179
__ ® �, /�1 0 Southold, New York 11971
JUDITH T.TERRY ---.:-.•,/so" 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. 1262-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FINNERTY, DONALD AND GERALDINE
Mailing Address 1 1530 FLEETWOOD ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1530 FLEETWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 137.00 block 5 lot 12.001
Cross Street EAST ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/11/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �t�f`U �'-
Town of Southold ,> C'� = Application No. /02 6 2-2
Judith T. Terry, Town Clerk % �: sTAY i `
$10.00 - Residential P/
Town Hall, 53095 Main Road a s ,�
P. 0. Box 1179 to #-- c•,._11:17:40. , $25.00 - Non-Residential
Southold, New York 11971 • �` 0
Telephone ®j41 P L� J11�d D
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE Lpin
OWNER NAME: AR. sQ �,nAt 1-; n/N.C7y
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OWNER MAILING ADDRESS: /5 F"1ee{woa,D .69,b
C`itt-Choeue. /II //,-3..s—
OWNER
-'3SOWNER PROPERTY ADDRESS: 54-r„e_ ns A--$. v-,--
OWNER TELEPHONE NUMBER: /�
14-7,,,---6 M2,/
TAX MAP NO. : Section e / Block /2 Lot
. CROSS STREET: SYS / RI
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° TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New xistin�
CResidential) 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.)
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RECEIVED BY: .
Town Clerk's Office
DATE:
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