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1„ tTown Hall, 53095 Main Road
:� P.O. Box 1179
® n ”'-�/ .,�'�,��. Southold, New York 11971
JUDITH T.TERRY -=,®t 6-
111;„ TELEPHONE
TOWN CLERK -�< i/iiiO4° (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 898-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GREENE, HELEN
Mailing Address 1 6083 - 68 ROAD
Mailing Address 2
City St Zip RIDGEWOOD NY 11385-0000
Property Address 1 MAIN BAYV I EW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 718-821-7459
Tax Map No. section 87.00 block 5 lot 19.001
Cross Street CEDAR DRIVE
Date Of Last Pump Out 0/00/77
,
Issue Date: 11/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ='wry(
Town of Southold ��fA CQG'_, Application
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ! Residential
P. O. Box 1179 Non-Residential
Southold, New York 11971 O S. ` '= <' *$
Telephone •
(516) 765-1801 •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (0 ('O 0
DATE 6Cr 9g'�
- OWNER NAME:
OWNER MAILING ADDRESS: OS" .b —1 P-4
Q.-W o 6 L( I( s-5
OWNER PROPERTY ADDRESS: t', i1-01\ U --w
soT IU y (( 38- S"
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 0'7 Block ' C, Lot /
CROSS STREET: C R
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - New Existing t."--
Residential
Residential L/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: l o .
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 Applic nt
RECEIVED BY: /471
Town C erk's Office
DATE: l06
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