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Town Hall, 53095 Main Road
P.O. Box 1179
*Th ����d Southold, New York 11971
JUDITH T.TERRY � 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. 1555-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PRICE, WILLIAM H. JR.
Mailing Address 1 P. O. BOX 2065
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 2074 BOURBON LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-1016
Tax Map No. section 59.00 block 3 lot 14.000
Cross Street KENNEY'S ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
bFFICE OF THE TOWN CLERK S�FFJIL
town •ef Southold ,Q _ C" Application No. ,S
Judith V Terry, Town Clerk y'ti'SK'.5 1
Town Hall, 53095 Main Road a .. $10.00 Residential
P. O. Box 1179 cry -r y-.• i:r. ; ' ` $25.00 - Non-Residential
Southold, New York 11971 O ® �`
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Telephone _�j ' ',•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. ,
Fee $ •
. DATE /0 /O ^ 'v
'OWNER NAME: 7/,,X,1;17- it �/ « LIT--
OWNER MAILING ADDRESS: FP �p t76,j
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OWNER PROPERTY ADDRESS: v 7 474
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OWNER TELEPHONE NUMBER: 477 /0(�
TAX MAP NO. : Section Block Lot
CROSS STREET: /r- l7111S p,(
TYPE OF SSTEM: Septic Tank New Existing
% ��‹ inA 1.1-- Cesspool New Existing
l � I,,i Residential Non-Residential
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DATE OF PREVIOUS PUMP-OUT: 6-1111.- /i -_
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.)
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RECEIVED BY:
-Town Clerk's Office
DATE:
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