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Town Hall, 53095 Main Road
r �` P.O. Box 1179
1� �!! Southold, New York 11971
JUDITH T.TERRY �;��'��� FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1133-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GUNTHER, HERBERT AND LINDA
Mailing Address 1 805 DONNA DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 805 DONNA DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9407
Tax Map No. section 115.00 block 16 lot 7.000
Cross Street NEW SUFFOLK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKc'SFULA'
Town of Southold , p%0-1(rt ; C�G• Application No. l V32
Judith T. Terry, Town Clerk ,Rt y
Town Hall, 53095 Main Road i r� �u .G 1 Residential
P. O. Box 1179 'trA Non-Residential
Southold, New York 11971 O01%-o
Telephone
Telephone ,( 41(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ' 0 , 07)
DATE /c'j
OWNER NAME:hligebieigl Li d,4- &, �
OWNER MAILING ADDRESS: R-OS' 400 W19 l)
OWNER PROPERTY ADDRESS: &D, /9,14, ,v.4 , 2eju,>
OWNER TELEPHONE NUMBER: .C/6 a9 -- c,/,y2
TAX MAP NO. : Section �,: Block //,‘ Lot ,-.1.-F-":"% 7
CROSS STREET: ,//,f& A% d
TYPE OF SYSTEM: Septic Tank 3( New Existing X
Cesspool New Existing ,<'
Residential Non-Residential
V-LOCDATE OF PREVIOUS PUMP-OUT: 7017 / 'ç.— ,6ertoeeo /4/-
LOCATION
ATION 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:
RE-C, %gun Clerk's Office
DATE: JUN 06 1939
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APPROVED i S NOTED
DATE: Vlohli- g.p.
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FEE: - •( — .Y: )-1) (-`-'• L •
NOTIFYDUR.D.. .1.0 .-EPARTMENT AT
765-1802 C) M IC. 4 PM FOR THE
FOLLOWING n45PEC” IONS:
1 1 FOUiL.;DAT0:..);f; TWO REQUIRED
FOR CC:'.CRS.TE
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2. ROUGH F2::.!4...4:744. & PLUMBING
3. INSULAT;ON
4. FINAL C.C....'STRU TION MUST
BL: C:311.1.il.ETE FO' C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIUMENTS OF THE N.Y
STATE CONSTRUCTMI & ENERGY
CODES. NOT RESPO. SIBLE FOR
...
DESIGN OR COrtSTR CTION ERRORS.
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