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Home My WebLink AboutRandlett Town Hall, 53095 Main Road P.O. Box 1179 _` ® •y sZ �� .,$' Southold, New York 11971 JUDITH T.TERRY '-:��` `2s' ��l��l 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. 1282-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner RANDLETT, JUDITH L. Mailing Address 1 BOX 423 Mailing Address 2 INDIAN NECK LANE City St Zip PECONIC NY 11958-0000 Property Address 1 INDIAN NECK LANE Property Address 2 City St Zip PECONIC NY 11958-0000 Owner Telephone No. 516-734-6856 Tax Map No. section 98.00 block 1 lot 2.014 Cross Street LESLIE ROAD Date Of Last Pump Out 0/00/87 Issue Date: 10/23/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) di--11C OF THE TOWN CLERK C,vFFVA,�' Town of Southold Q ." l� Application No./ ,-i_ Judith T. Terry, Town Clerk �e s a �� $10.00 - Residential r� Town Hall, 53095 Main Road 41:4 . P. O. Box 1179 cn �Yr;Y ; .z • $25.00 - Non-Residential Southold, New York 11971 O ® `= '`_ e�` Telephone ai 1�� '� (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT • SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ LC9 - DATE &Ct.: 9 � OWNER NAME: J(.Q"d j HI / , kfkocilett- OWNER MAILING ADDRESS: fro / d t: Qr. S r , w V.(5) L Lq OWNER PROPERTY ADDRESS: OWNER TELEPHONE NUMBER: cg TAX MAP NO. : Section 0 q g, 0--c Block 0 ( . 0 CS Lot d 0 )- ,0 ILf CROSS STREET: Le_ StLe, 240 TYPE OF SYSTEM: Septic Tank New Existing Cesspool ,X New Existing x Residential A Non-Residential DATE OF PREVIOUS PUMP-OUT: 07'0( /7 7 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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