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OFFICE OF THE TOWN CLERKF�
Town of Southold ��� C�lj
Judith T. Terry, Town Clerk .� yri '
Town Hall, 53095 Main Road c .
:
P. O. Box 1179 ‘11 `t
Southold, New York 11971 ® ®- t.O- !
Telephone 40/ 'Ape..
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 362 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Stanley R. Gould
OWNER MAILING ADDRESS: P.O. Box 903
Cutchogue, N.Y. 11935
OWNER PROPERTY ADDRESS: 2830 Nassau Pt. Rd.
Cutchogue, N.Y. 11935
OWNER TELEPHONE NUMBER: 734-5449
TAX MAP NO. : Section 104 Block 12 Lot 18.1
CROSS STREET: Vanston Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X - Non-Residential
DATE OF PREVIOUS PUMP-OUT: 5/15/87
Judith T. Terr 1 -
Southold Town Clerk
DATE: , July 23, 1987 :-
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �OFG(,(le'-
A lication No.
Town of Southold •�� 473 CQG' pp
Judith T. Terry, Town Clerk
�� ���L �=', Residential
Town Hall, 53095 Main Road "igti
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- P. O. Box 1179 , �. Non-Residential
Southold, New York 11971 O -® t ":+y..
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(516) 765-1801
_ TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4 ;':
Fee $ 1 o_ on
DATE ] `q - E.7
OWNER NAME: S TAN E Y cfOI) ]_p
OWNER MAILING ADDRESS: f
(5 Y G ( q Q 3
cut lioGuri w• ' - 1i93,s'
OWNER PROPERTY ADDRESS: 4.1 20 IvA5'ifi () FT. _R
Cdvrall 06oviisrt • °I• Illi
OWNER TELEPHONE NUMBER: 73 if 5111
s TAX MAP NO. : Section /0L/. VI- Block If. Lot t
CROSS STREET: V a v.f ,ni r- D a_,e4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: t-A187
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.)
/I,..I {L
Sign:1) ure of Applicant
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RECEIVED BY: sem,,.. _/ ,� ��J
own Cle k's Office
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