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JUDITH T. TERRY O Town Hall, 53095 Main Road
•TOWN CLERK rift ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS • EJB •` Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER O ®-
�,y®� � ti Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3143-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STERN, JONATHAN P.
Mailing Address 1 BOX 792
Mailing Address 2
City St Zip ORIENT NY 11957-3792
Property Address 1 700 BIRDSEYE ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2673
Tax Map No. section 17.00 block 2 lot 1 .003
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/16/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �C31FULA'
Town of Southold �% . 0Q -- Application No. 5/ q3
Judith T. Terry, Town Clerk % ,,; ''1
Town Hall, 53095 Main Road c : s, $10.00 - Residential
P. O. Box 1179 cc -.z ';; % $25.00 - Non-Residential
Southold, New York 11971 O $
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Telephone -..°1 * �►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL -
Operation Permit No.
Fee $ /O .
DATE Noor 47 1p9_g
OWNER NAME C To p / .i 4), ' ---57��'"ei
OWNER MAILING ADDRESS: y ( 7 2 0f' ( ell; I i ? S7
/ /
-- - _ -- OWNER
rc nvPERrv ADDRESS:
7unESS: 7s}Q -
ii-Jc, _" � .
S/ -1' Iseid 1 •( ,t)r / / ," fir? - Day''' -
OWNER TELEPHONE NUMBER: / Cr, (� � 3 7-L 6, 7
TAX MAP NO. : Section /7 Block Lot /, 3
CROSS STREET: hca-e-1---- 2A " e-- -- a-
TYPE OF SYSTEM: Septic Tank ew Existing ../"-----
Cesspool
Cesspool New Existing
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: C' — —
LOCATION MAP: Must be attached hereto before permit may berIssued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Signature of Applicant
RECEIVED BY: t, / Xi-4- ...
o n Clerk's Office
DATE: // /1-/ �3
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