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JUDITH T. TERRY _ ` Town Hall, 53095 Main Road
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P.O. Box 1179
TOWN CLERK
=;3 �' _' : ff01 t, Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
�� D ��' Fax (516) 765-1823
MARRIAGE OFFICER
• 'N �1` Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1823-R Residential X Non-Residential
Fee $ - 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAVANA, PHILIP A.
Mailing Address 1 3080 ROOUTE 112
Mailing Address 2
City St Zip MEDFORD NY 11763-0000
Property Address 1 807 FRONT STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-736-7171
Tax Map No. section 48.00 block 1 lot 6.000
Cross Street 8TH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 12/19/9. 1 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK •,�FF�
Town of Southold ��C ..= A'CQ ' Application No./
Judith T. Terry, Town Clerk �
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Town Hall, 53095 Main Road 8 �" � ,, = •4 $10.00 - Residential
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p. O. Box 1179 ' = ;' $25.00 - Non-Residential
Southold, New York 11971 OF •�
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Telephone =
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O
DATE 46,/f/
PHILIP A.SAVANA C.P.A.
OWNER NAME: 3080 ROUTE 112
MEDFURD N.Y.11763
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: 6e 7 620 '•1` 6 9-
&-e i&.ter- /19s
OWNER TELEPHONE NUMBER: 574;-- 7310-7171
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
ignature of Applicant
RECEIVED BY: ..
Town Clerk's Office
DATE: