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tE, Town Hall, 53095 Main Road
P.O. Box 1179
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��r Southold, New York 11971
JUDITH T.TERRY --11.4-%;-.~107/0-,�l� 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. 1426-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MILLER, DORIS P.
Mailing Address 1 P. O. BOX 305
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 1935 OLD ORCHARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1612
Tax Map No. section 37.00 block 3 lot 8.000
Cross Street LOCUST COURT
Date Of Last Pump Out 0/00/86
Issue Date: 3/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
o
OFFICE OF THE TOWN CLERKc. -
Town of Southold e.Q Application No. P/024
Judith T. Terry, Town Clerk k �. '' 4 444.%=
Town Hall, 53095 Main Road >;r� .< $10.00 - Residential
P. O. Box 1179 '_'. s :•:44 i $25.00 - Non-Residential
Southold, New York 11971 O • ® .4W7 ��`
Telephone ��j liret 1 .e
(516) 765-1801
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No. ,l1-/q7 ,
Fee $ / ) `.
. DATE 4j/ .,.,, .. . / ''''. iff o
OWNER NAME: DA pe, 1s P. iti) ' L LEA. •
OWNER MAILING ADDRESS: J 6 adv 3
EAS1* MA as ow Mot. it I) 3 7 .
OWNER PROPERTY ADDRESS: ma.s-, k cpi _g,c) iRQ Dr
E4s7 emA Rho V ictil y li ? ft,
OWNER TELEPHONE NUMBER: y77 . ) / A.4 .
TAX MAP NO. : Section S 1 Block ` • ki Lot •,,A ®ie5 ti
CROSS STREET: aj — •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: AritatJT N S A4 •
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.)
41.1- -----46%\---z Zir I4 - ' _.-.-
`ature of Applica t
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RECEIVED BY: x_ace- 0. 4-ea- LJ
Town Crk's Offl'ce
DATE: