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�; Town Hall, 53095 Main Road
® ®�-��� P.O. Box 1179
' �QA * ��i.► Southold, New York 11971
JUDITH T. TERRY '��0w//'/'OTELEPHONE
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. 1072-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAHM, ROSE
Mailing Address 1 P. O. BOX 1113
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 HILL ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3829
Tax Map No. section 70.00 block Li lot 31 .000
Cross Street HARPER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/05189 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK /c3UtO e.
Town of Southold 0�� �, i "016 Application No. /O-7.2-'
Judith T. Terry, Town Clerk . y
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Town Hall, 53095 Main °Road �.._ Residential
`:
P. O. Box 1179 =« � ;wi �' Non-Residential
Southold, New York 11971 ��`�
Telephone ®.(V 'I
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
"
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /d 7 - -
Fee $ je.)
DATE 3 /4/ / g7
OWNER NAME: R® 5e, .sA•y y)
OWNER MAILING ADDRESS: WL a RacLA Fo, 8,,, 6 113 "
6t, , Nry- a16171
OWNER PROPERTY ADDRESS: .01( 111
5tna74h.ol�. Alt < 11971
OWNER TELEPHONE NUMBER: s`/1, 7
TAX MAP NO. : Section 70 Block Lot 3
CROSS STREET: � �kfer Ram.-.e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing i-
Residential Non-Residential
-DATE OF PREVIOUS PUMP-OUT: / // e42/3
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.)
01110.
Signature of Applicant
RECEIVED BY: oetr-, �
Yerk's Of ice
• DATE: PAPR U b 1� -
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