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JUDITH T. TERRYTown Hall, 53095 Main Road •
CLERK , ® - �` � P.O. Box 1179
REGISTRAR OF V VITAL STATISTICS ` �• Southold, New York 11971
MARRIAGE OFFICER '� )4 Fax (516) 765-1823
®� / 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. 1759-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHROEDER, TODD V. SR.
Mailing Address 1 305 BIRCH LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 305 BIRCH LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6025
Tax Map No. section 83.00 block 1 lot 29.000
Cross Street DUCK POND ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/20/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •S�FFOUr"-
Town of Southold CQ ' Application No. /761/
Judith T. Terry, Town• Clerk ` A-z, $xe
Town Hall, 53095 Main Road -� 10.00 - Residential
P. O. Box 1179 �� ` n �L z $25.00 - Non-Residential
Southold, New York 11971 O ® k‘\--
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- _ - - - - - - for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1\ )
DATE (c: 14
OWNER NAME: 1 � �
OWNER MAILING ADDRESS:
\\ - T �--
OWNER PROPERTY ADDRESS: -- - -
OWNER TELEPHONE NUMBER: ��� � �
TAX MAP NO. : . Section Block Lot
• CROSS STREET:
TYPE OF SYSTEM: Septic Tankw Existing
- - Cesspool New Existing
' Residential - Non- esidential
DATE OF PREVIOUS PUMP-OUT:
OUT: \10
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.)
-4.mwalr
ak1146, 4 -
Signature of Applicant
RECEIVED BY:.
Town Clerk's Office -
RECEIVED -
DATE: _ ..
SEP 191991
Town Clerk Southold
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