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JUDITH T.TERRY - FAX(516)765-1823
TOWN CLERK
"'���� TELEPHONE(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. 1156-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOFFAT, EVELYN
Mailing Address 1 PINE NECK ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 BOISSEAU AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3278
Tax Map No. section 55.00 block 6 lot 14.000
Cross Street- NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKS1FUA- "-
Town of Southold C Application No. ll
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 v3
$25.00 - Non-Residential
Southold, New York 1197.1 O �•`
Telephone( *6?(516) 765-1801 V
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ,f3
OWNER NAME: .-OWNER MAILING ADDRESS: / f /Vpk
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
• TAX MAP NO. : Section 5-5 Block (Q Lot /
CROSS STREET:
TYPE OF _SYSTEM: Septic Tank • New Existing
Cesspool 47- New Existing
Residential L/ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
0./4.44_4 j...4)
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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Si ature f Ap cant
RECEIVED BY: V
Town Clerk's,Office
DATE: '