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,:„ -,; , M` _ Town Hall, 53095 Main Road
�"" ` ` P.O. Box 1179
' Southold, New York 11971
JUDITH T.TERRY a4 , 11 FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1353-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FRANK B. ROGERS SR.
Mailing Address 1 26550 ROUTE 25
Mailing Address 2
City St Zip CUTCHOGUE, NY 11935-0000
Property Address 1 26550 ROUTE 25
Property Address 2
City St Zip CUTCHOGUE, NY 11935-0000
Owner Telephone No. 516-734-6640
Tax Map No. section 109.00 block 4E lot 8.000
Cross Street PRAITY LANE & MAIN ROAD
Date Of Last Pump Out 7/23/88
-601re°44;',..
Issue Date: 12/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK c�OFO(,� '
G
Town of Southold • CS
� ' Application No. / 3'.3
Judith T. Terry, Town Clerk t#4. w T y
�- ,^N .G
Town Hall, 53095 Main Road - � '� -� . $10.00 - Residential 6/
p. O. Box 1179 �.,::r� .,.;f:,�. �� h�i � $25.00 - Non-Residential
Southold, New York 11971 Q �yVt '' 0���`.
Telephone j `'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / 3S3
Fee $ /p o 0
DAT S ,D,4 \cc Sct
'OWNER NAME: efi •
D ES -� CG
OWNER MAILING AS: IQo��S�
OWNER PROPERTY ADDRESS: : !00-„C.S)
OWNER TELEPHONE NUMBER: .5-)01P r-- 6 6 7 v
TAX MAP NO. : Section y Block L Lot
CROSS STREET: ceo, Q
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ✓
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: I / g''
LOCATION MAP: Must be attached hereto be ore permit may be issued.
(Locate building and system; give northarrow and feet
of distance, approximately, to building and closest road.)
Signature of Ap i nt
RECEIVED BY: i/1 _
ow r~ Cler 's Office
DATE: /�/�7 -
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