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Town Hall, 53095 Main Road
eap 6�� `' P.O. Box 1179
�� 06� Southold, New York 11971
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JUDITH T.TERRY FAX(516)765-1823
= „� TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TD �OWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1149-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GOLDSMITH, ALLAN T.
Mailing Address 1 5005 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 5005 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7320
Tax Map No. section 110.00 block 4 lot 2.000
Cross Street FLEETWOOD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FFU ,
Town of Southold ���, G
;: �o ' . Application No. �'
Judith T. Terry, Town Clerk , ` „; y
Town Hall, 53095 Main Road 8 zp . .
7 Residential
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P. O. Box 1179 cn .': ;�ra.= i `' Non-Residential
Southold, New York 11971 it,-
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Telephone _ .� fix` •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE fp l%,2i
OWNER NAME: 4,
OWNER MAILING ADDRESS: -c-S�D'S �, ��
Com , �e 3
OWNER PROPERTY ADDRESS: (\oLw.e�
OWNER TELEPHONE NUMBER: c00-
TAX MAP NO. : Section Block Lot•Z. CY-4A
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool (1.16°
Existing
I/ Existing
Residential ,7 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.)
Signature of Applicant
RECEIVED BY: �
oi1h�`( Ierk's Office
DATE: JUN 13 9b-1
t UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF
•• SECTION 7209 OF THE NEW YORK STATE
EDUCATION LAW.
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAt D SURVEYOR'S INKED SEAL OR
I 1—
-- -- -- -- - , - EMBOSSED SEAL SHALL NOT BE CONSIDERED
• TO BE A VALID TRUE COPY.
14
J I , = -7`/ GUARAt.TEES INDICATED HEREON SHALL RUN
• 1 lin ONLY TO 1HE PErSO;v FOR WHOM THE SURVEY
n- I 15 FRG ARED, AND ON H.S BEHALF TO THE
I TITLE COMPANY, GOVERNMENTAL AGENCY AND
'
/ ^i LENDING It-STiTUTION LISTED H.R:ON, AND
} TO THE ASSIGNEES OF TM LENDING INSTI-
_, —
�1 TUTION.GUARANTEES ARE NUT TRANSFERABLE
L. /- rl 'J TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT
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