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IA' Town Hall, 53095 Main Road
JUDITH T. TERRY AT
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �, ® Fax (516) 765-1823
03,! Telephone (516) 765-1801
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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. 1902-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SANGER, IRENE
Mailing Address 1 3050 GRATHWOHL ROAD
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 3050 GRATHWOHL ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6106
Tax Map No. section 110.00, block 8 lot 8.000
Cross Street OAK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ' '9�FFO�Cp
Town of Southold QS Application No.g.2?
Judith T. Terry, Town"Clerk' �� "N.
Town Hall, 53095 Main Road , �C,
,�� .,":iti.-� � $10.00 -
Residential
P. O. Box 1179 toMY Ay.'� ' •
*�=•- '�''% . $25.00 -
Non-Residential
Southold, New York 11971 °�
Telephone ,. O,� ��� ���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
'OWNER NAME: SHN • •
OWNER MAILING ADDRESS:" &‘,5 57.) �,� ��CeJ, 1'C- '
-D c."i(L
OWNER PROPERTY ADDRESS: S uj n'2 J
OWNER TELEPHONE NUMBER: 1 3 y- (, 2 U C
TAX MAP NO. : Section //0 d Block ' Lot
CROSS STREET: G
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing '
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: (/ C7. . Cf
/ V -
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.) -
Signature of Applicant
RECEIVED BY: -
Town Clerk's Office
•
DATE: _71(
1
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