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JUDITH T. TERRY ; . Town Hall, 53095 Main Road
TOWN CLERK z T P.O. Box 117.9
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ® ®� •
,�/®1 �1� 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. 3097-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PARLAMIS, ANNA MARY
Mailing Address 1 2525 BAYSHORE ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 2525 BAYSHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-2233
Tax Map No. section 53.00 block 4 lot 19.000
Cross Street KERWIN BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ���FFO p
Town of Southold ��� CQG' , Application No. 30i
Judith T. Terry, Town Clerk , i :'
Town Hall, 53095 Main Road - $10.00 - Residential 1✓
P. O. Box 1179 cry $25.00 - Non-Residential
Southold, New York 11971 O ®_ 0-/.Telephone *o( ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD-WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE a8 /793
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OWNER NAME: 1,0 h k1/41-- ��-aQkikr) s
OWNER MAILING ADDRESS: a5,7S B oac Rad cL
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OWNER PROPERTY Y ADDRESS: dj j A s chaPQ,e kp,fcI
-` R c.E nJ PoR-r, N Y, n'
OWNER TELEPHONE NUMBER: ''16),) ` . i - 22,3
TAX MAP NO. : Section 5 3 1 ? Block Lot 1-1-3
CROSS STREET:
TYPE OF SYSTEM: Septic Tank )' New Existing x
Cesspool New Existing )(
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT:. NON)
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,)
A— kst4,
ignature/f Applicant
RECEIVED BY: '
Town Clerk's Office'
DATE:
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