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��® Town Hall, 53095 Main Road
® P.O. Box 1179
/,,;�1'� 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. 1299-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHREMMER, GERHARD & BRIGITTE
Mailing Address 1 60 OLD PINE DRIVE
Mailing Address 2
City St Zip MANHASSET NY 11030-0000
Property Address 1 703 BAYSHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-627-2269
Tax Map No. section 53.00 block 6 lot 19.000
Cross Street ISLAND VIEW LANE
Date Of Last Pump Out 0/00/00
Issue Date: 11/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK � FO(,r
Town of Southold Q C'�G• Application No. / i_
Judith T. Terry, Town Clerk % 414 4.4.
$10.00 - Residential
Town Hall, 53095 Main Road ;°
P. O. Box 1179 tr3 $25.00 - Non-Residential
Southold, New York 11971 0 till% ��`�
Telephone ( `h '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT'
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. --
Fee $ /0
DATE I( G (e?
OWNER NAME: -CO"( fes- !�! /u E �� •
6S� F •
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OWNER MAILING ADDRESS: 0 021)
K 0- SS F-7- fv `-( ((020
OWNER PROPERTY ADDRESS: 70 3 S t"tro-R-E
62- Pr 1 ( 97 �
OWNER TELEPHONE NUMBER: S-16 - 62_ 7 -- 2-2_6
TAX MAP NO. : Section ) 5--3Block
CROSS STREET: WE- V J L;D 4 7 . T 2-Ls7 i
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 may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
‘-n7Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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TOWN OF SOUTHOLD
Ticket No. 1 r.,3..t.
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:s.s FA -„Ei tejv xw$
iv.
SCAVENGER WASTE REPORT -- 44„.-N,-, --, Fee: $.02 per gallon
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----„,,00 Fee $. ,- 7)--. paid
Name of Hauler. . .c7X-.4):U.1/4.-ek .0-444/2-0:-(e(---) ' ' Date /.7 p7. 7-.s .j. pad i .,
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Permit Number a? Southold Town Clerk . .
Truck Capacity c75-Q0Gallons Liquid Waste
Date Pumped. 4
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' 7- (.7 .
Residential Commercial • Restaurant
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Location: i / / / -
6- Name of Ownee4 r ce 0'
0
41''- Street /03 6 V..4.-ce Hamlet
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Telephone NTbeh. "Z .7g\..5.--/Tax Map Number
0 \Cross Street.N••>lo. tes.4 .
j..-. Diagram (locating building and cesspool. Give north arrow and feet of distance,
: approximately.),g
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',:,,, I hereby certify that the above originlated within the Town of Southold at the above
location(s), and to the best of my knowledge, contains no chemicals, hazardous or toxic
waste. All statements made hereby are made punishable as a misdemeanor pursuant to
Section 210-45 of the Penal La of ,he State of New York.
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Name of Driver . pik _..‘,,,A
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Signature of Driver . .
' - Received by ---
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Date Time
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(1) Treatment Plant
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