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Town Hall, 53095 Main Road
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�`� P.O. Box 1179
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OFFICE OF THE TOWN CLERK C0FO(,r
Town of Southold ��.r . C'Q -- Application No. 0 C V
Judith T. Terry, Town Clerk F _ - �►
Town Hall, 53095 Main Road ,. . .,: -'c Residential
P. O. Box 1179 cr3 w *� Non-Residential
Southold, New York 11971 O ' Ili 'X',,.. $
Telephone 44 0 '';
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1 u.
DATE 3-344
OWNER NAME: iRark o7)9_01. 1,eh
OWNER MAILING ADDRESS: ROI. 10271
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OWNER PROPERTY ADDRESS: \( qo BO,s5ecw. Avg-
50 Lot-cv 01.6
OWNER TELEPHONE NUMBER: IGS, ZI 2(p
s
TAX MAP NO. : Section 55 Block (p Lot ) 9
CROSS STREET: ,,,w / 1.. 'd.pir _ E. e
TYPE OF SYSTEM: Septic Tank New Existing 1i'--
Cesspool New Existing it.------
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 09-0-e-4--- '
o
f distance, approximately, to building and closest road.) '
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Signature of plicant
RECEIVED BY: ,
Town Clerk's Office
DATE:
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