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Town Hall, 53095 Main Road
v'® �- �� P.O. Box 1179
1�® ►� Southold, New York 11971
JUDITH T.TERRY � TELEPHONE
TOWN CLERK (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. 745-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FLORA, MICHAEL
Mailing Address 1 P.O. BOX 600
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2301
Tax Map No. section 70.00 block 8 lot 54. 000
Cross Street GRANGE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/0 a "-.1„
OFFICE OF THE TOWN CLERK cOFUCA-
Town of Southold :� :.,�. CQG' .ii Application No�T
Judith T. Terry, Town Clerk . r5;�. .„, ...016.°
Town Hall, 53095 Main Road er '' '..-44. :4 ' Residential
P. O. Box 1179 cf3 ,, .•, �•y,r� ��z Non-Residential
Southold, ,�� ' ' '
New York 11971 O`�� - .�0� ���
Telephone �► '�
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee I
DATE 6°7 e/16.
OWNER NAME: Al4EC /542 2 7- ./:-.74-7'1--. 2
OWNER MAILING ADDRESS: /'4' 9 r• 1(700
/k //S
OWNER PROPERTY ADDRESS:
7..<.(--5,— /g ,� le,,,// i 3
OWNER TELEPHONE NUMBER: 7e14 , --Yp/
TAX MAP NO. : Section -lf Block e Lot 5 G/
CROSS STREET: //z„--7,«, ,�
0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool c--'-----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
Lo of distance, approximately, to building and closest road:)
R,.1....7
•
i,' ....---___ _--- 2—
Signature of Applicant
RECEIVED BY: :f'
Town CIe-e)c's Office
DATE: 't aV,' "e
JUN -2 8198
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