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OFFICE OF THE TOWN CLERK �FFD
Town of Southold ��5� COG', Application No. •0
Judith T. Terry, Town Clerk . r ' � Residential
Town Hall, 53095 Main Road a <z -
P. O. Box 1179 v' 'Ph .` Non-Residential
Southold, New York 11971 O $
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Telephone ,
(516) 765-1801 -
RECL`V TOWN OF SOUTHOLD
DEC; ED
04 lesc-3. SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Tothm r '1' South l;'
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No. /0�
Fee $ /0 '
DATE /6"3/•
OWNER NAME:
(/)'° y A/ 6. . G . f9 ACV
OWNER MAILING ADDRESS: la ,/Iceio/s/ L A222
5e./t-/=OLS'
OWNER PROPERTY ADDRESS: .f !0 mil
OWNER TELEPHONE NUMBER: -7357— C.0 I f
TAX MAP NO. : Section //// Block ziL Lot
CROSS STREET:
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.)
'.nature of Applicant
-
RECEIVED BY: _ce.-c
Town C rk's Ovtice
—
DATE: /ca' E,D0 -19
ion Meth Soutnold
OFFICE OF THE TOWN CLERK w' .i-VQ(x`,G
Town of Southold • �b
Judith T. Terry, Town Clerk "
Town Hall, 53095 Main Road , ux
P. O. Box 1179 _ '
Southold, New York 11971QT'�l �0�. •�,
Telephone of t
1.
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 183 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: John G. Glander
OWNER MAILING ADDRESS: Grathwohl Road
New Suffolk. New York 11956
OWNER PROPERTY ADDRESS: Grathwohl Road •
New Suffolk. New York
OWNER TELEPHONE NUMBER: 516-734-6619
TAX MAP NO. : Section 117 Block 4 Lot 5
CROSS STREET: George Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
•
Judith T. Terry
Southold Town Clerk
DATE: December 19, 1986
i
(TOWN SEAL)
JOHN G. GLANDER
NEW SUFFOLK. NEW YORK 11956 (516) 734-6619
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