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Town Hall, 53095 Main Road
I�` P.O. Box 1179
�� se Southold, New York 11971
JUDITH T.TERRY -- ®1 /�i0 .l TELEPHONE
. 516 7
TOWN CLERK ( ) 65-1801
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. 859-R Residential X Non-Residential
Fee $ 10. 00 Septic X Cesspool
New Existing X
Name Of Owner FLAHERTY, EDWARD F.
Mailing Address 1 FLAHERTY, BRENDA T.
Mailing Address 2 1215 PINE TREE ROAD
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1215 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7554
Tax Map No. section 98.00 block 1 lot 7 .013
Cross Street BILLARD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/27/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK S\\FFO(,( -
Town of Southold �f � •; Application No. �57
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road "sem Residential
Cry `,..�' , #ur'?°
P. 0. Box 1179s . i�� Non-Residential
Southold, New York 11971 Off;® $ 14 ��
Telephone 0,( 1‘�O
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Dd DO
DATE 1 -aa-88
OWNER NAME: Ed 1,c3orcd F &A f3 revidA T F/o- Aer
OWNER MAILING ADDRESS: /c2/S /,'i& Free- ieoad
C°c-Cf ����� tl. 'f //9 3S
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 576 — 2.34-/ - 75-5-4 {
TAX MAP NO. : Section 9'2.v Block 1 — Lot 7 /3
CROSS STREET: j3j/I Q rd Road
TYPE OF SYSTEM: Septic Tank New Existin
Cesspool 1/ New E/S�cisting 1�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: �--�-J-GT SCS /� =KC�Z/
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.)
OF
Signature of Appli .nt
RECEIVED BY:
Town Clerk's Office
DATE:
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TO THIS SURVEY IS A •
K SECTION 71C9 Of THECDWARD . � rAI � 0Y �JEDUCATION LAW.
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COPIES OF THIS SUM