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JUDITH T. TERRY ' Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
C2). � Fax (516) 765-1823
MARRIAGE OFFICER �'�! 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. 1895-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHULZ, WILLIAM O. AND KAREN A
Mailing Address 1 16 WASHINGTON AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 16 WASHINGTON AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-2725
Tax Map No. section 41 .00 block 1 lot 41 .000
Cross Street MAIN STREET
Date Of Last Pump Out 0/00/00
Issue Date: 5/11/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c���FO(,e•
Town of Southold O '14'4' Application No. /cP15
Judith T. Terry, Town Clerk �� ' . '.
Town Hall, 53095 Main Road "_ $10.00 - Residential
r,
P. 0. Box 1179 to rte11444i $25.00 - Non-Residential
Southold, New York 11971 ®' 'O /'`��
Telephone 0.( �'1� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $r o
DATE 3
OWNER NAME: L a,II IQ c Q . a„-N(t_ Pc. sal, L
OWNER MAILING ADDRESS: V0 LiuCts.delina Rt-e.
Cbreenpnr-1- N (1 q LtV
OWNER PROPERTY ADDRESS : Same, az
OWNER TELEPHONE NUMBER: 447 7— a -7 a 5
H- I - go - L
TAX MAP NO. : Section 4- Block Lot
CROSS STREET: Main .
TYPE OF SYSTEM: Septic Tank \ New Existing •
Cesspool N New Existing N
Residential Non-Residential \•
DATE OF PREVIOUS PUMP-OUT: S/q
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 ApplicaOt
RECEIVED BY:
Town Clerk's Office
DATE: -
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