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JUDITH T. TERRY : Town Hall, 53095 Main Road
•TOWN CLERK rZ P.O. Box 1 179
REGISTRAR OF VITAL STATISTICStb � Southold, New York 11971
MARRIAGE OFFICER �® ' •'� Fax (516) 765-1823
4 1D •� Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3006-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner @ICALE, SARAH WICKHAM
Mailing Address 1 58 GROSVENOR ROAD -
Mailing Address 2
City St Zip BUFFALO NY 14223-0000
Property Address 1 160 EAST ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 716-876-7376
Tax Map No. section 110.00 block 7 lot 17.000
Cross Street PEQUASH AVENUE
Date Of Last Pump Out 8/00/89
Issue Date: 4/27/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
. r OFFICE OF THE TOWN CLERK cwFFDUr�
Town of SoutholdCQG Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road '" :' $10.00 - Residential
P. O. Box 1179 ` $25.00 - Non-Residential
Southold, New York 11971 Opyo® ��.. �- ,
Telephone ( '
(516) 765-1301
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1cD.03
OWNER NAME: - a,i 'C(.A 66- a G` i(a-le
OWNER MAILING ADDRESS: eq-c$vei1o7 `
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bviktio
OWNER PROPERTY ADDRESS: 14‘20 g-��'' Arid ---
OWNER TELEPHONE NUMBER: 7'l(p 8�(p )37(p
TAX MAP NO. : Section HQ Block '7 Lot I '7
CROSS STREET: P90, 71'Ue(1(7Q
TYPE-OF- SYSTEM: Septic Tank -- New Existing
Cesspool New Existing -✓
Residential I 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.)
// x.44 ! I4 ill/
ignature o Applicant
RECEIVED.BY: _
Town Clerk's Office -
DATE:
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