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JUDITH T. TERRY T Town Hall, 53095 Main Road
TOWN CLERK
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS r Southold, New York 11971
MARRIAGE OFFICER® *trFax (516) 765-1823
N-t40 • 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. 1841-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHNEIDER, LOW
Mailing Address 1 840 TOWN HARBOR LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 840 TOWN HARBOR LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5546
Tax Map No. section 64.00 block 5 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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I IIS
OFFICE OF THE TOWN CLERK •S�FFd(,� �.
Town of Southold ® CQ ', Application No.���
Judith T. Terry, Town Clerk e„ �``) $10.00 - Residential
Town Hall, 53095 Main Road ( w ,
p. O. Box 1179 � ,�-��,,, ' � $25.00 - Non-Residential
Southold, New York 11971 OJ7 � T e
Telephone •
= 1 Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. i n` f
Fee $ /d
DATE ;---//11/4
OWNER NAME: j eO �„I -�/ �T✓
OWNER MAILING ADDRESS: nOrT,Liki VL'v
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 9 J -'
TAX MAP NO. : Section Clock lit Lot .S
CROSS STREET: NlCt ITt S+ 6- ' 1-)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool L/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 990
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.)
242, 40,
s Sigriature of Applicant
RECEIVED BY: f
Town Clerk's Office
DATE:
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