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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® f P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �` Southold, New York 11971
MARRIAGE OFFICER ® ) Fax (516) 765-1823
4A®d ��, 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. 1961-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GILBERT, ROBERT W.
Mailing Address 1 1490 PARADISE POINT ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1490 PARADISE POINT ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3333
Tax Map No. section 81 .00 block 3 lot 20.000
Cross Street CEDAR BEACH ROAD
Date Of Last Pump Out 3/15/87
Issue Date: 8/26/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• II•
OFFICE OF THE TOWN CLERK 05�FF0(,tr�'•
Town of Southold �% CQ Application No. 756 7
Judith T. Terry, Town Clerk M F
Town Hall, 53095 Main Road `{ $10.00 - Residential ✓'
P. O. Box 1179 �5 ' 4(r `' $25.00 - Non-Residential
Southold, New York 11971 ,37-
Telephone )0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /9&(
Fee $ / 0-
DATE t ' 'i' r !qqA
OWNER NAME: I�j�,�(3 ERT Cv' e1LB R
'T-
OWNER MAILING ADDRESS: /WO PA- -A 1S E Po4.'r e04,9
E060-1401.4) .y, 11971
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: rib 76J--- 33.33
TAX MAP NO. : Section, Block p Lot
CROSS STREET: ear' ftgra, taw
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ',C Non-Residential
DATE, OF PREVIOUS PUMP-OUT: 3 // S_)e-7
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: ( I
Town Clerk's Office
DATE: /c
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