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f y r, ,; Town Hall, 53095 Main Roadcrt ',- � -' P.O. Box 1179
"'---,„ 111 �i�� Southold, New York 11971
JUDITH T.TERRY _�,�, yr'���� TELEPHONE
TOWN CLERK (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. 693-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner MEINKE, MARGARET
Mailing Address 1 6 ROCKY RIDGE DRIVE
Mailing Address 2
City St Zip TRUMBULL CT 06611-0000
Property Address 1 6955 PECONIC BAY BLVD.
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 203-378-7191
Tax Map No. section 126 . 00 block 10 lot 14. 000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
II
OFFICE OF THE TOWN CLERK I = / C 33
Town of Southold �� sr �Q ' . Application No. �P I
Judith T. Terry, Town Clerk � 0-FeY �
Town Hall, 53095 Main Road o Residential
P. O. Box 1179 U' 3 z � Non-Residential
Southold, New York 11971
Telephone 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: /f2%7 -r 7f4//V,fr
OWNER MAILING ADDRESS: i9C,k1V r.72.)6-612)1/2 f
OWNER PROPERTY ADDRESS: b 5--- CW/c. '/ t3U 1/_7
ivty )
OWNER TELEPHONE NUMBER: ZU 3 - 37S - 7/97
TAX MAP NO. : Section % 2-6 Block jb' Lot / 7
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool " New Existing 1/
Residential r'" Non-Residential
DATE OF PREVIOUS PUMP-OUT: A ft IVDi,1//
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.)
/12 0.-tx}( / r).il.,,t/t-/C
Snature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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