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Town Hall, 53095 Main Road
® ®�' ' P.O. Box 1179
___ jam/,, s� : S. Southold, New York 11971
JUDITH T.TERRY e ®�� , �� FAX(516)765-1823
TOWN CLERK
�� TELEPHONE(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. 1105-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHEPARD, WARREN O.
Mailing Address 1 1925 WEST CREEK AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1925 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6352
Tax Map No. section 110.00 block 2 lot 6.000
Cross Street MIDWOOD ROAD
Date Of Last Pump Out 10/01/84
Issue Date: 5/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3VFF17(,- -
Town of Southold &� CQ Application No. / 1 0 5'
Judith T. Terry, •Town Clerk ►
Town Hall, 53095 Main Road a . : Residential
V in`,'Q`3, t
P. O. Box 1179 �'S `A *�.� Non-Residential
Southold, New York 11971 4�� ���`�
Telephone _ F �►�� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /(�
DATE : -2 gf`�
OWNER NAME: w,/=(I`{�ai D 5-744-(0,yg o
OWNER MAILING ADDRESS: (q2c W 57' cQ':eK 147PE
C° uTCH46LJF
OWNER PROPERTY ADDRESS: 5 f??E
OWNER TELEPHONE NUMBER: 74L �
TAX MAP NO. : Section 110 Block 2/ Lot
CROSS STREET: rvu] j c)OOz) Re7/7l)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 6/ New Existing
j Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3 ` 3o •-/ -8i
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 Ap+ icant
RECEIVED BY:
`: down Clerk's Office
DATE: . 0 1039
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