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JUDITH T. TERRY o-.
4v '� { '�' Town Hall, 53095 Main Road
TOWN CLERK ® I P.O.pt `ft 5'71 t
Box 1179
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REGISTRAR OF VITAL STATISTICS �.LSI 574:%*
Southold, New York 11971
-� '� Fax (516) 765-1823
MARRIAGE OFFICER ' � 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. 3081-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POOLE, NANCY
Mailing Address 1 BOX 751
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2131
Tax Map No. section 31 .00 block 4 lot 13.000
Cross Street STARS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/05/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.1\VF[1(,r��=
Town of Southoldt� .. - e& "" Application No. 3Y4 Y
Judith T. Terry, Town Clerk F,t ►
Town Hall, 53095 Main Road - $10.00 - Residential
P. O. Box 1179 tri KAY
' ; $25.00 - Non-Residential
Southold, New York 11971 � *-$
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ Cb•1 'r
� G/32
DATE (•�
OWNER NAME: IOCANet) TO-6--Q •
OWNER MAILING ADDRESS: 'c c 76 ( c. r r `Ctl( dC91A
OWNER PROPERTY ADDRESS: \prveis 1,1 Q MQ1(T. err\
OWNER TELEPHONE NUMBER: L(C7 1 - 2 k 3
TAX MAP NO. : Section 2, / Block q Lot t 3
CROSS STREET: 5\C, 5 ,
TYPE OF SYSTEM: - Septic Tank ' _-. New Existing
Cesspool ,X New Existing
Residential >< Non-Residential
DATE OF PREVIOUS PUMP-OUT: \r\i\_a.kr C,Crl RC( 3
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.)
'gnatu'e of A plicant
RECEIVED BY: fel - - -
- : - . Town ' ler-k's Office
DATE: C " -
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