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JUDITH T. TERRY ac Town Hall, 53095 Main Road
TOWN CLERK rrri P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS ih Southold, New York 11971
MARRIAGE OFFICER
10° Nr •� Fax (516) 765-1823
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14. 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. 3003-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner REITER, JOSEPH AND BARBARA
Mailing Address 1 55 BIRCH LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 55 VIRCH LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5658
Tax Map No. section 83.00 block 1 lot 31 .000
Cross Street DUCK POND ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •0�FFO � (
Town of Southold �5 - " CQ Application No. 0
Judith T. Terry, Town Clerk ry
Town Hall, 53095 Main Road - 0 4 : $10.00 - Residential
p. O. Box 1179 tri i" re71 � $25.00 - Non-Residential
Southold, New York 11971 O s
Telephone,( `ge� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE App-k ) 3 )619.3
OWNER NAME: jo s er In I • ar► d 6a r 6q,ra D , Re
OWNER MAILING ADDRESS: 5 5 , r0
C, u-1-GA, 03 ue j New `{ork \\a 35
OWNER PROPERTY ADDRESS: 5 5 e y Cr In La lies/
C� v►-��_ Ddb Lt f New 1 O cA< i1G135
OWNER TELEPHONE NUMBER: 5 l - 13 61 _ 56 5 7
TAX MAP NO. : Section Block l Lot
CROSS STREET: 0 0,(`Y. 'l'o►�lc� k� )ci
TYPE-'OF -SYSTEM: Septic Tank New Existing
Cesspool New Existing I/
Residential (7 Non-Residential /
DATE OF PREVIOUS PUMP-OUT:V2-,r-V VUrnQ-c� 33)15 [ g3
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.)
Ler *-CD
Sign ur- of Applicant
6
-RECEIVED-BY!'
Town Clerk's Office
DATE:
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