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•••,...0.4:0'maf ', �,�; Town Hall, 53095 Main Road
`':'; �' P.O. Box 1179
` '_�®( it ��®i.. Southold, New York 11971
JUDITH T. TERRY '1,..*,,,#"A''' TELEPHONE
TOWN CLERK (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. 1050-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROM, RUDOLPH
Mailing Address 1 BUNNY LANE
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 BUNNY LANE
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5013
Tax Map No. section 117.00 block 6 lot 28.001
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/81
Issue Date: 3/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK .0" cvFFO1r.'=
Town of Southold C� = Application No. /74�d
Judith T. Terry, Town Clerk .„ ;Ft.! 4,
Town Hall, 53095 Main Road :.� F y�i_ :'� 7 Residential
P. O. Box 1179 u' t_ w� h�i Non-Residential
Southold, New York 11971 O0 ` VO '�``
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Telephone = 1 yN
(516) .765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: A° (/2l ,lLo
OWNER MAILING ADDRESS: EcCa//Z4'
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7 a
')(TAX MAP NO. : Section Block Lot J_(1r-r-
CROSS STREET:
•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: , .7 �'-5•
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.)
Jr
" Si:na re of applicant
RECEIVED BY:
2E, own Clerk's Office
DATE:_ 11A I5 ���°�
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