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Town Hall, 53095 Main Road
kt . ;.'`$ : P.O. Box 1179
®� � '� Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1458-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHILLINGER, LOUIS
Mailing Address 1 P. O. BOX 247
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1285 FLEETWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5683
Tax Map No. section 137.00 block 4 lot 29.001
Cross Street BETTS STREET
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�vFFO(,r -
Town of Southold &% -,-K "0 Application No. /`/53
Judith T. Terry, Town Clerkrt �
'r� -< $10.00 - Residential
53095 Main Road
Town Hall, � z ��.+
P. O. Box 1179 �' i4 t $25.00 - Non-Residential
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Southold, New York 11971 OVA °' ��
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,-R
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DATE
'OWNER NAME: -2J fICA/� -yx_c,z ) •
OWNER MAILING ADDRESS: / 5
/ P2L5
OWNER PROPERTY ADDRESS: /0-0,-
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OWNER TELEPHONE NUMBER: 22 00
TAX MAP NO. : Section /3 '7 Block Li Lot 029. /
CROSS STREET: -gq476; � z- o
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r/ New Existing v
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3 T_co_
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: 4c-1(LiCz C.�
Town Clerk's Offiice
'%:11014.:;
DATE:
MAT 1419:.:1
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