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JUDITH T. TERRY
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1577-R Residential X Non -Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner REINHARD, MARGARET
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Mailing Address 1 4747 NORTH ROAD 33 - #449
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Mailing Address 2
City St Zip
Property Address 1
Property Address 2
City St Zip
Owner Telephone No.
Tax Map No. section
Cross Street
Date Of Last Pump Out
Issue Date: 11/20/90
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LAKELAND FL 33805-0000
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505 BEACHWOOD ROAD
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CUTCHOGUE NY 11935-0000
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516-734-6801
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116.00 block 4 lot 23.000
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DEAN DRIVE
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5/00/78
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1801
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Judith T. Terry
Southold Town Clerk
( TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Application No.
$10.00 - Residential ✓
$25.00 - Non -Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 2L -e,1,• 71 /!/ jo
OWNER NAME:—
OWNER
AME:OWNER MAILING ADDRESS:7�7
Ll
OWNER PROPERTY ADDRESS: .o �6' AG
x 3 Ma777"/-Tz,,',=/ . A/,Y•
OWNER TELEPHONE NUMBER:S / �0 7 3 - go j
TAX MAP NO.: Section Block Lot
CROSS STREET: 6 L - 7A /V [7 r?lV-,5-
TYPE OF SYSTEM: Septic Tank- New Existing
Cesspool New Existing
Residential 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.)
A A P A a X 3 a' *-L�m � o-�s-
G
(Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: