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OFFICE OF THE TOWN CLERK �✓� �c��FFEJ1X
Town of Southold � _ DGy;
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road � T.
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P. O. Box 1179 y�
Southold, New York 11971 ;O` - '�
p 41
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 226 Residential X
• Non-Residential
Fee $ 10.00 Septic Cesspool x
NAME OF OWNER: Hermine Shillmer
OWNER MAILING ADDRESS: 230 Bridge I ane
Cutchogue, New York 1193.5
OWNER PROPERTY ADDRESS: 230 Bridge Lane •
Cutchogue. New Ynrk
OWNER TELEPHONE NUMBER: 516-734-5077
TAX MAP NO. : Section 111 Block 15 Lot 1 .4
CROSS STREET: Wunneweta Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terry C/
Southold Town Clerk
DATE: February 23. 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �� �( ��-
Town of Southold &_N) � ' Application No Z'
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a 41-- Residential
cn
P. O. Box 1179 Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. cgon,
Fee $ /6
DATE ./( /f/7
OWNER NAM 4,1-v .-
OWNER MAILING ADDRESS �> •‘ /�` � j/I���
4 � �
OWNER PROPERTY ADDRESS: f� e
3% "TAOWNER TELEPHONE NUMBER: 739--
TAX
X MAP NO. : Section /1 ) Block /.3 Lot f- V
CROSS STREET: ) v Rd
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t/ New Existing -
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
47/4 / .6//,p,f4A
Signature of Applicant
RECEIVED BY: 65w
R own erk's O fice
DATE: FEB 19 1987
Town Dirk Southold
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