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OFFICE OF THE TOWN CLERK •cvFFU(,- '
Town of Southold s,. ti CQG'� Application No. /U' 7
Judith T. Terry, Town Clerk ` x y g/
, -<•. ,_ :.0 1 Residential
Town Hall, 53095 Main Road ,
P. O. Box 1179 u' '4,!.;:. .1-)= ' ` Non-Residential
Southold, New York 11971 G , _O�'es
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. .'
Fee $ /O )
DATE 7- /,1)-7y
OWNER NAME: �� �'��/'/, c.% 7/-1/3--/1.7
OWNER MAILING ADDRESS: ft i )-J7 '
//1p,vy1 /l/Y. (o 7 4
OWNER PROPERTY ADDRESS: /2--1/ d-/ Fir 144- rood
62--ai-f,ifa7 cel,' / Af,,/, //%7th
OWNER TELEPHONE NUMBER: L/ 1— -) y5'' ° ,/%71-7/r/‘` 73 ‘i- `2 " r
TAX MAP NO. : Section /0 Block V Lot Z/-3
CROSS STREET: 117/2(F c /ed. S/ri.LN/ii //gj11g- /% /6 A.2 •r/ /1,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r� 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.)
0 ...&_......0.41-&gate
S-'i.natu ry'o ' p p/OF
RECEIVED BY:
irtzit:4i . .?wn Clerk's Office
. DATE: MAR 31. 9-- .
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