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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
MARRIAGE OFFICER � ® .- ®4r*,�1, Fax (516) 765-1823
®.1 **4Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2037-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, MRS. HERBERT
Mailing Address 1 P. O. BOX 654
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 275 MAIN BAYV I EW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3518
Tax Map No. section 70.00 block 5 lot 53.000
Cross Street PINE NECK ROAD
Date Of Last Pump Out 0/00/80
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •S�FFO(,- =
Town of Southold % . . CQ Application No. o�!/
Judith T. Terry, Town Clerk . �t�, LItt y _
Town Hall, 53095 Main RoadR ''-� '� $10.00 Residential
P. O. Box 1179 u' s;_ AN.. hi . $25.00 - Non-Residential
Southold, New York 11971 O
Telephone 1
-4- 0);°.°
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATIONPERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $
DATE to/i ((IR,
OWNER NAME: ''Y 15, er b i Si-ri i I h
OWNER MAILING ADDRESS: Q (j f)( _
5cjufhoIC''�� � i •y, 11Q`l
OWNER PROPERTY ADDRESS: J -mClll1 15(3„utt)teu� R(t
nufhnic , Nuy, i 1ql 1 .
OWNER TELEPHONE NUMBER: ( i ) 7c,S-- 3518
TAX MAP NO. : Section '70 Block 6- Lot 6 3
CROSS STREET: flu N` e-c L�c�
TYPE OF-SYSTEM: Septic.Tarik 7 New 6 Existing 4
Cesspool 1// New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: g-C.2
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.)
Signature of Applicant
RECEIVED-BY: --- • -
Town
ECEIVED-BY: ---
Town Clerk's Office
DATE:
o O
CO '