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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
�� Fax (516) 765-1823
MARRIAGE OFFICER ® ®� •
yo �� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2049-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHACK, MARIE
Mailing Address 1 146 PLEASANT STREET
Mailing Address 2
City St Zip WOBURN MA 01801-0000
Property Address 1 1265 SHORE DRIVE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 617-935-1168
Tax Map No. section 47.00 block 2 lot 26.000
Cross Street SILVERMERE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKc.3vFFO(,II‘."
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Town of Southold �� CQG' Application No. a0 T/
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Judith T. Terry, Town Clerk '
53095 Main Roads .•C $10.00 - Residential
Town Hall, c i - Non-Residential
p. O. Box 1179 u' $25.00
Southold, New York 11971 O = �•`�
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 00/23
OWNER NAME: 1(1(G(tit , Shack
• OWNER MAILING ADDRESS: I .b' ) ZO� S+-
0turkl) 7i11 a Olro/
OWNER PROPERTY ADDRESS: / 6 Shore hitt
Gruen oi- 'YUv'f- 1'19
OWNER TELEPHONE NUMBER: 6/7' -
J35 006,6
TAX MAP NO. : Section if 3 (31 / Block 4-T-(R-2.6 Lot
=CROSS STREET:
TYP.E,OF, SYSTEM: 'Septic:Tank- - - - -- --New Existing
Cesspool )(, New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (,Pyr4,46N A"PuErC 6 /1-°/.
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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.)
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VP/W
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Sign ur of Applicant
RECEIVED ,BY: , , • _ ._ __. __.
Town Clerk's Office
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