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Town Hall, 53095 Main Road
P.O. Box 1179
®d . Southold, New York 11971
JUDITH T.TERRY = ���iir�ii/� 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. 1226-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STOTT, ROBERT L., JR.
Mailing Address 1 20 BROAD STREET
Mailing Address 2
City St Zip NEW YORK NY 10005-0000
Property Address 1 PARADISE POINT ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3138
Tax Map No. section 81 .00 block 3 lot 24.000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �;���FFj �'- /
Town of Southold C' • A lication No. Ic262o
Judith T. Terry, Town Clerk • +
< °�lMf� , .G I $10.00 - Residential
Town Hall, 53095 Main Road �:
p. 0. Box 1179 in A `�` hi
� � ���� �� $25.00 - Non-Residential
Southold, New York 11971 O "�_ .,�7tr-P. ,-��`
Telephone 01 `• .°'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • •
DATE /20 /d"
fY
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A/3)6;erJJ570 / pOWNER NAME: ,/. / �J'
OWNER MAILING ADDRESS: �U ,d/POJ/ sr-
4/,y,
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/t/,y, ,4/. too, I-3---
OWNER
2$OWNER PROPERTY ADDRESS: P,4 i'/9 L)s6 id-7-: led
S6011nLi_7 i /V,7, /17 7/
OWNER TELEPHONE NUMBER: ,j/6 - 265--- 3/3 P
TAX MAP NO. : Section . 7/ Block 3 Lot c24`
CROSS STREET:
•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V/ New Existing 4/
Residential 1 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. ,
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Adipti.;4., #.__I .
Signature of Applica
RECEIVED BYC.-W A_ , l,LQee7r,
Town Clerk's Office
DATE: ' ° I @D.W •
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