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,�` Town Hall, 53095 Main Road
��1 P.O. Box 1179
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® 00 Southold, New York 11971
JUDITH T.TERRY FAX3
TELEPHONE)7682 765-1801
TOWN CLERK )
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. 1240-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHEPPARD, HARRY
Mailing Address 1 5638 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 5638 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5341
Tax Map No. section 110.00 block 5 lot 35.000
Cross Street WEST STREET
Date Of Last Pump Out 6/15/88
Issue Date: 9/01/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�VF (�FO • //,
Town of Southold ��f._ CQG' Application No. 4210
Judith T. Terry, Town Clerk 3_ y
Town Hall, 53095 Main Road o <'~ -4 ` Residential
• P. O. Box 1179 u� "' `� z' i ;' Non-Residential
Southold, New York 11971 • *0/
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Telephone _ ,(_Jr I
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f(516) 765-1801 O
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
UMW
for
SEP 01. 1969
OPERATION PERMIT
we 04 SOHO.
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
-
_ - - ---DATE • /.
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OWNER NAME: �/ / r
OWNER MAILING ADDRESS: �j I� _
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OWNER PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot
CROSS STREET: Wied—/13161------
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (p 1 /5- nf-
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.)
)1�p_` 0/Lad-f-'7
- - Signature of Applicant
RECEIVED BY:,
�?�g�yapCle,
Towt rk's Office
DATE: '
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