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JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK : =v T P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = VO` �. Fax (516) 765-1823
MARRIAGE OFFICER ' as„0"� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3160-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FORBES, SUSAN
Mailing Address 1 SLAC IK, CLAUDIA
Mailing Address 2 1075 NARROW RIVER ROAD
City St Zip ORIENT NY 11957-0000
Property Address 1 1075 NARROW RIVER ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2477
Tax Map No. section 27.00 block 3 lot 6.002
Cross Street KING STREET
Issue Date: 1/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c,�FFU1'��=
Town of Southold CQG' Application No. 3/Z
Judith T. Terry, Town Clerk . "' ;, 4- �`� $10.00 - Residential
Town Hall, 53095 Main Road a
il-P. O. Box 1179 cry ; $25.00 - Non-Residential
Southold, New York 11971 �` ".t---1. '��`�
Telephone -1 * N�0 '.i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. L.3 /b zi
Fee $ l• D„ D v
DATE /z_, y/g 3
OWNER NAME: rusAi✓ `oie6•gs f c,.._Au ',5, ,1'z� c/K
OWNER MAILING ADDRESS: S'4-P.,� /9-S d L e--dw
OWNER PROPERTY ADDRESS: /o 7 S N/9-,e2o fr✓ ,c / ✓,act /c.v
•
c)..e ,t,✓T iv•r. / 9,5 7
OWNER TELEPHONE NUMBER: 3z 3 2 Y 7 7
1
TAX MAP NO. : Section 2 7 Block ' 3 Lot co . o O "2-
CROSS
CROSS STREET: k,N c, ,s r .
• TYPE OF ,SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: w/n
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 oficant
RECEIVED -BY: - �� -
To n CI r c's Office
DATE: P-7?-77
• /os 7 -