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f`1;}) a' Town Hall, 53095 Main Road
� t� P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY
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� •• FAX(516)765-1823
` • TELEPHONE(516)765-1801
TOWN CLERK
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. 1430-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FRANKE, JANE M.
Mailing Address 1 BOX 174
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3546
Tax Map No. section 70.00 block 1 lot 5.000
Cross Street TUCKERS LANE
Date Of Last Pump Out 0/00/64
Issue Date: 3/30/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK • S\\TFair
Town of Southold , Application No.) Li 3-0
Judith T. Terry, Town Clerk . # '141461
Town Hall, 53095 Main Road ;„ $10.00 - Residential
p. O. Box 1179 <s b<Yi
.; i��;, : � $25.00 - Non-Residential
Southold, New York 11971 O "® `"O�,•��`
Telephone Q( `A�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0h 0-0
DATE 90
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OWNER NAME: 0 �)
OWNER MAILING A9DRESS: /
OWNER PROPERTY ADDRESS: A.gyir24)1A...(4_,_.;) ,,,/. /.,,,-eet_./A/,/:/5e7/p.,- 7
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OWNER TELEPHONE NUMBER: 6-/6, -- 766--
TAX
TAX MAP NO. : Section 70,1 ock / Lot
CROSS STREET: elZt �,t Zc¢14/L.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ 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
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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