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JUDITH T. TERRY �� i� Town Hall, 53095 Main Road
: P.O. Box 1179
TOWN CLERK
REGISTRAR OF VITAL STATISTICS . } rrit 4tr5Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
�® 6 Telephone (516) 765-1801
NW Aso.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1690-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, JAMES B. JR.
Mailing Address 1 495 WEST SHORE DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 495 WEST SHORE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1413
Tax Map No. section 80.00 block 2 lot 2.000
Cross Street OAK STREET
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK SOFO(,( -
Town of Southold {,. C'� Application No. 16
Judith T. Terry, Town Clerk a _
Town Hall, 53095 Main Road <t %'1 $10.00 - Residential (-/
P. 0. Box 1179 cnZ, . n •
�,;_� $25.OQ - Non-Residential
Southold, New York 11971 O ® •°�` �' •�`
Telephone of [ �► '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION ,PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 0 f
DATE 5 J 9i
OWNER NAME: _\•ice S r-n i I'_ •
OWNER MAILING ADDRESS: 9,s— cks) s-1101F Dr-
-s6 041-0 H NY //97/
OWNER PROPERTY ADDRESS : S'191-1
OWNER TELEPHONE NUMBER: I6,S1- ) 5 /3
TAX MAP NO. : Section 2 0 Block Lot
lTYPECROSS STREET: (30al--
TYPE
OF SYSTEM: Septic Tank New Existing
Cesspool LS‹.. New Existing ;c
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MA: 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.)
A 1 )atilt'
gnat "e of Applicant
RECEIVED BY:
Town C erk's Office
DATE: J av
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