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Town Hall, 53095 Main Road
*c�® O ff,)� P.O. Box 1179
�� ®� t Southold, New York 11971
JUDITH T.TERRY ••�� TELEPHONE
TOWN CLERK (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. 3596-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SCOTT, DEBORAH M.
Mailing Address 1 700 MCCANN LANE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 700 MCCANN LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-2234
Tax Map No. section 33.00 block 4 lot 17.000
Cross Street SUTTON PLACE
Issue Date: 3/10/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FF4.�.
Town of Southold Oho Q %=\ Application No. t 5-9
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - - $10.00 - Residential
P. O. Box 1179 z � i $25.00 - Non-Residential
Southold, New York 11971 4 ® /�`�
Telephone
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3/ In Cr lry
•
OWNER NAME: r Yc,-OL v14L
OWNER MAILING ADDRESS: 70L >1k
OWNER PROPERTY ADDRESS :
1
OWNER TELEPHONE NUMBER: �y�` 42 -- 42 7 -
TAX MAP NO. : Section ?13 Block Lot. /`�
-2.CROSS STREET: - r � /
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I/ New Existing
Residential Non-Residential
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.)
vAJ
Signature of Applicant
RECEIVED BY: /17—
Town Clerk's Office
DATE: 6//a/g
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