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JUDITH T. TERRY • Town Hall, 53095 Main Road
TOWN CLERK p rZ P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS _ � Southold, New York 11971
Fax Fax (516) 765-1823
MARRIAGE OFFICER •
',y0 * 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. 2012-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GOLZ, ARNOLD R.
Mailing Address 1 P. O. BOX 1513 -
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 6910 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1579
Tax Map No. section 59.00 block 9 lot 26.008
Cross Street HOPE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 12/02/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK oI „'•'•
Town of Southoldv.C& Application No.I
Judith T. Terry, Town Clerk . , 45 �►
Town Hall, 53095 Main Road � $10.00 - Residential
ti
P. 0. Box 1179 cry = v_-,: z $25.00 - Non-Residential
Southold, New York 11971O ®,'fir
Telephone _ ( l •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT E C E I V E
D
APPLICATION - Nov 24 4
for Southold Town Clerk
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE k2.0®Q12
OWNER NAME: A r r \ &AZ.
OWNER MAILING ADDRESS: ?o `60k i \'-3
OWNER PROPERTY ADDRESS: (ogla Sc,und);€ o 'Ave - NO \ oee ane.
OWNER TELEPHONE NUMBER: C 1(o� `1(.0 -k "kct
TAX MAP NO. : Section oSck Block ®°I Lot o2(,0,,
CROSS STREET: Cox-v-s r �o0(\d \eu0 v2k1N0p \r.ctv-AR
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - ,/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: V-)n
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.)
„,„
Sign tture o Applicant
RECEIVED BY:
TcCun Ierk's fice
DATE: tf' ,c2 0-
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