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OFFICE OF THE TOWN CLERK ' 0Ure�G,"
Town of Southold -
Judith T. Terry, Town Clerk g_.f ' % -
Town Hall, 53095 Main Road - C
P. O. Box 1179 {-K,`. �
Southold, New York 11971 0emjn-
Telephone --..1.45:6/ $%6
(516) 765-1801 '`
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 298 Residential
Fee $ 10.00 Non-Residential
Septic Cesspool x
NAME OF OWNER: Donald Staron
OWNER MAILING ADDRESS: Box 299
Peconic, New York 11958
OWNER PROPERTY ADDRESS: 1780 Henrys Lane
Peconic, New York -
OWNER TELEPHONE NUMBER: 516-765-2053
TAX MAP NO. : Section 74 Block 2 Lot 4
CROSS STREET: Soundview Avenue West
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Ter
Southold Town Clerk
DATE: May 5, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKFUC,r "
Town of Southold �� ;_. CSG Application No.af,
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road . :' Residential v''
P. O. Box 1179 cn a ` :' Non-Residential
Southold, New York 11971 0���`
Telephone Oi ',
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - _ _ _.
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l O.o D
DATE ,_3/S/./2
OWNER NAME: 5-11,4+.o-t3 /off`
OWNER MAILING ADDRESS: Ni 2-P1.6
OWNER PROPERTY ADDRESS: `1.cfp 05
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section /y Block Lot
CROSS STREET: S e91)I& kV( W
TYPE OF SYSTEM: Septic Tank, / New Existing
Cesspool ✓ New Existing
Residential 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.)
Signature of A plicant
RECEIVED BY:(
own C rk's Of ice
DATE:
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