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JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK p T P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS tri Southold, New York 11971
MARRIAGE OFFICER ®r •
, Fax (516) 765-1823
jig__',�►01 11D � Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3017-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, HENRY J. AND STELLA
Mailing Address 1 P. O.BOX 176
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 1350 ROBINSON LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-6990
Tax Map No. section 98.00 block 4 lot 28.001
Cross Street INDIAN NECK LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK oc�V�FD(,�'��`_ .,
Town of Southold � .*� CQG Application No. '® "7
Judith T. Terry, Town Clerk ; :'
Town Hall, 53095 Main Road $10.00 - Residential
p. O. Box 1179 tri �� $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.30 1 -7
Fee $ t O
DATE 73
OWNER NAME: HENRY J. AND STELLA SMITH
OWNER MAILING ADDRESS: P.O. BOX 176, ROBINSON LANE, PECONIC, N.Y. 11q58
OWNER PROPERTY ADDRESS: 1350 ROBINSON LANE, PECONIC, N.Y. 11958
OWNER TELEPHONE NUMBER:516-734-6990 ( .contact son at, 516-765-3642)
TAX MAP NO. : Section /00 0 r Block OV Lot P, ,
CROSS STREET: )N t/ i A/eG/C'
TYPE OF„SYSTEM: Septic Tank- -- - New Existing
Cesspool New Existing
Residential x 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.)
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Sig atu e of "T licant'
RECEIVED BY: j �” /
Town Clerk's Office
DATE: � /9 - - - - - - - - - - _ _
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