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JUDITH T.•TERRY Town Hall, 53095 Main Road
TOWN CLERK Z. G T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
y •� Fax (516) 765-1823
MARRIAGE OFFICER ® O� •
_�,y®� � �1 � Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2046-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FURLONG, MARY P.
Mailing Address 1 P. O. BOX 1183 -
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1745 NAKOMIS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3045
Tax Map No. section 78.00 block 3 lot 35.000
Cross Street HIAWATHA'S PATH
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1.
OFFICE OF THE TOWN CLERK c���FO(,('�--
Town of Southold �% ter. ea ;% Application No. ?Q y
Judith T. Terry, Town Clerk . YLi Isy
Town Hall, 53095 Main Road . :.4 $10.00 - Residential ,--
p. 0. Box 1179 v' rrif ,` . $25.00 - Non-Residential
Southold, New York 11971 O
Telephone 5 ?e ~ 'i "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ J O . IV
•
DATE 1 Igs193
OWNER NAME: ,A (7 'L ' URLop'/6
OWNER MAILING ADDRESS: F' 0 -00)( I I '.a
S (4,r-oo) , Nii 119n
OWNER PROPERTY ADDRESS: I -7 `L5 (V'A i`'< (DM I S ,)?OA D
„So o T-H-O c. b) /11V 11 ? -7 /
OWNER TELEPHONE NUMBER: , 766-- -.30z74 3---
TAX MAP NO. : Section `7 7 Block 3 Lot 3 5----
CROSS
�CROSS STREET: J-J I a 0 pl'( (-I A(s PAI P
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing )<
Residential y Non-Residential
DATE OF PREVIOUS PUMP-OUT: W0 7" trl DO Ai (1)05c715.
i il 'iLail
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.)
//1/(1-- r- '11;--(-11
Si vnature f Applicant
RECEIVED BY:
(A.,i/d-4—.
Town Clerk's Office
DATE: / (9-- 7 '2
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