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Town Hall, 53095 Main Road
®��® 4,1-�,�� P.O. Box 1179
o„ Southold, New York 11971
JUDITH T.TERRY ,ii/,i" 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. 1573-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SINGLETON, HESIKIAH & ETHEL
Mailing Address 1 704 WIGGINS STREET
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 704 WIGGINS STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0837
Tax Map No. section 48.00 block 1 lot 19.000
Cross Street SEVENTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 10/30/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF-THE TOWN CLERK 'S�FFULA"
Town of Southold � C'0 "- Application No. 15
-
Judith T. Terry, Town Clerk ,�.� »;, y //
Town Hall, 53095 Main Road f;� :< 7 $10.00 Residential
P. O. Box 1179 cry .z r 16 �` $25.00 - Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4.6.-2
Fee $ fed. '
DATE /0 •" e:/9c:1
'OWNER NAME: S,, - S-e"-} /�� e_ 1 , j •
OWNER MAILING ADDRESS: ?e�L G�'f�y/,LrcY
-e_,��f7 /77I y
OWNER PROPERTY ADDRESS: S ,�} heNr e_
OWNER TELEPHONE NUMBER: 57 -- Y. 77 - O Z. 3
TAX MAP NO. : Section Block / Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing •
Cesspool ✓ New Existing
Residential Non-Residential
DATE
DATE OF PREVIOUS PUMP-OUT: S/
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.)
Sigdatur—of Ap o Iicant
RECEIVED BY: ,h1/ /1"12
Town Clerk's Office
DATE: /O -
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