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Town Hall, 53095 Main Road
i'r P.O. Box 1179
eel $4)'" Southold, New York 11971
JUDITH T.TERRY V_ FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1364-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MEEHAN, JAMES J.
Mailing Address 1 700 BAY HAVEN LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 700 BAY HAVEN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2619
Tax Map No. section 88.00 block 4 lot 21 .000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/11/90 Judith T. Terr '� „
Southold Town Clerk
(TOWN SEAL)
I
OFFICE OF THE TOWN CLERK c.\FFR/yr '-
Town of Southold CSG Application No.
O� 1
Judith T. Terry, Town Clerk r
Town Hall, 53095 Main Road ��
$10.00 - Residential X
p. 0. Box 1179 � ` '} •i • L $25.00 - Non-Residential
Southold, New York 11971 O ® 't }`
Telephone *4,j '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: Gly , `e„ -No •
OWNER MAILING ADDRESS: —JN 5 &w1 \ v e i -e
OWNER. PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: (o , c2A0 ) 9 _
TAX MAP NO. : Section Block Li Lot 1
CROSS STREET: r_A‘ C1 �Jl .
TYPE OF SYSTEM: Septic Tank )c New Existing
•
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ;c7
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.)
/7,
/ Sign ure of Applicant
RECEIVED BY:
Town Clerk's Office - -
DATE:
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