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JUDITH T. TERRYz Town Hall, 53095 Main Road
TOWN CLERK p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS a($1 . %`
r Southold, New York 11971
MARRIAGE OFFICER � ® � Fax (516) 765-1823
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3089-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROWSOM, GEORGE H.
Mailing Address 1 BOX 837
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 825 MUNN LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-1177-1990
Tax Map No. section 17.00 block 2 lot 7.001
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COFOU.
Town of Southold A QG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ` „ - $10.00 - Residential
p. 0. Box 1179 tb•%. ,yz '� $25.00 - Non-Residential
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Southold, New York 11971 6ik0 '-fir �O�''`
Telephone = 1 � • '0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit
NNo.
2511/ (,(5iFee $
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v DATE yty/g�
OWNER NAME: Ge—On /4 CZ S&m
OWNER MAILING ADDRESS: lo, 23 7
OWNER PROPERTY ADDRESS: 1 1mro v `,Cayt---/
• OWNER TELEPHONE NUMBER: Cs-4 L/77 / (Q
TAX MAP NO. : Section ff1 Block Lot 7, I
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CROSS STREET: Lam)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 2(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Sig ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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