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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® 7i, is P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER '® .;Y Fax (516) 765-1823
_��® tsLi3 �� I�!' Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3049-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MILLIGAN, THOMAS
Mailing Address 1 865 RUCH LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 865 RUCH LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4165
Tax Map No. section 52.00 block 3 lot 7.000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �0��FFU�
Town of Southold � • CQG'; Application No. 36�
Judith T. Terry, Town Clerk �`'� $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 ; $25.00 - Non-Residential
Southold';., New; York 11,971 . ,,,; .s ;.
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Telephone " , , .. Oj ` `�► �' .. _
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
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OPERATION PERMIT
- SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE Cto\ ` rl \93
OWNER NAME: N1/4 its Of)'LL.kC. -)
OWNER MAILING ADDRESS: 'FS
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OWNER PROPERTY ADDRESS: .1tftryNtv0
OWNER TELEPHONE NUMBER: ((oci ^'°1/4-c1IA
TAX MAP NO. : Section 4113 Be9 Block 5'2 Lot 3
CROSS STREET: NOWLT14 1L
TYPE OF SYSTEM: Septic Tank New Existing /'
Cesspool V New Existing v
Residential NV Non-Residential
DATE OF PREVIOUS PUMP-OUT: -
LOCATION
UMP-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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Signature of Vicant
RECEIVED BY: • .
Town Clerk's Office
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DATE:
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