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u raj Town Hall, 53095 Main Road
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P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY � �" '� 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. 1388-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, JOHN C.
Mailing Address 1 465 TOWN HARBOR LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 465 TOWN HARBOR LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3024
Tax Map No. section 63.00 block 4 lot 7.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 2/21/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c.1 HU(Town of Southold �' ,_� COG Application No. /3 ,C -
Judith T. Terry, Town Clerk .4.4* ,6"'•
Town Hall, 53095 Main Road^ ;� :'� $10.00 - Residential
V, r"f•'�11 F �II
p. O. Box 1179 • $25.00 - Non-Residential
Southold, New York 11971 LS '� �$
Telephone ?
(516) 765-1801
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL --b
Operation Permit No.
Fee $
•
DATE / gi9
�U
'OWNER NAME: _ a (4I�j,.__...�
OWNER MAILING ADDRESS: 9'C,( "IOWA) �ILA
(SOwi/iauj pivew tio/L4
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OWNER PROPERTY ADDRESS: "e /�r
�`� f -Ad 04
OWNER TELEPHONE NUMBER: 67C 7 ' —
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: -- U/k 1q 81
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.)
Sig'ature of Applic-nt
RECEIVED BY: A
"Town Clerk's Office
DATE: Z `Z-a (J
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