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JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ® Southold, New York 11971
rt MARRIAGE OFFICER � Fax (516) 765-1823
,0004 Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1667-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIDOR, ROBERT
Mailing Address 1 730 SIGSBEE ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 730 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5091
Tax Map No. section 143.00 block 1 lot 9.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
- • i;.
OPFI•CE OF' THE TOWN CLERK Sc0Ffltir - •
Town of Southold &% CQG' Application No. 4c 7
Judith T. Terry, Town Clerk _
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 $25.00 — Non-Residential
Southold, New York 11971 '�! ��'J��
Telephone _01 `?� �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT , •
SEPTIC TANK or CESSPOOL
Operation Permit No. 7
Fee $ . /6
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DATE AUc I ptGD -
'OWNER 'NAME: ' Dbef t
OWNER MAILING ADDRESS: -7 30 51 GS'SEE Rci
OWNER PROPERTY ADDRESS: 51-Prej
OWNER TELEPHONE NUMBER: a t9 c•_ 509
TAX MAP NO. : ' Section } ' 3 Block -Lot , 9
t� -
CROSS STREET: �,I� RDI ,'- • -
TYPE OF SYSTEM: Septic Tank—
New - 'Existing
i
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.)
to 4
Signature of Applicant
RECEIVED BY:Z
To n -Clerk's Offic - 9 g
DATE:
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