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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 �� Fax Fax (516) 765-1823
i �' �! Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1868-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SOULLAS, ESTHER H.
Mailing Address 1 P. O. BOX 1150
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 27475 MAIN ORAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-333-7415
Tax Map No. section 102.00 block 1 lot 13.000
Cross Street HIGHLAND ROAD S CASES LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/06/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I /i.
LOFFIC,c OF THE TOWN CLERKS \FFU
i�, ' Town of Southold �5CQG'_ Application No. ���
Judith T. Terry, Town Clerk1/47Ass
y
Town Hall, -53095 Main Road ` ;� .•G $10.00 - Residential
; r .
P. O. Box 1179 C13 •` h�i $25.00 - Non-Residential
Southold, New York 11971 O ®, =.±' ��`
Telephone V,(� ..4ros
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 •( b • ;'
DATE , 40#7.---
OWNER
40OWNER NAME: (tli S au t-a '
OWNER MAILING ADDRESS: ../1!111 Pc ,�OK 11 5-0
Ia rt km/ Nv 7 4-3(( '
OWNER -PROPERTY ADDRESS-: ("Mt 7,5" -
- cr if-c , 4JY 1(9-
OWNER TELEPHONE NUMBER: 333-79?‹ •
TAX MAP NO. : Section /0 4� Block ( Lot 3
, CROSS STREET: cQr� lb 4i4I / I Cil- -0" - •
TYPE OF SYSTEM:-. Septic Tank "-_" New Existing
Cesspool New Existing V
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 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.)
A.Of f,
4 Signature of Applicant
RECEIVED BY: 4-4-1(-- 6e--- - .. -- --
Town -Office .,
DATE: _ APR_ 6199
Town Clerk Southold
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