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JUDITH T. TERRY ;' at. Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : Southold, New York 11971
Fax 516 765-1823
MARRIAGE OFFICER t ( )
� �® ,�� 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. 1760-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOORE, DAVID J.
Mailing Address 1 21075 SOUNDVIEW AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 21075 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3226
Tax Map No. section 51 .00 block 4 lot 17.000
Cross Street CLARK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/20/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�\\VFOUI-
Town of Southold � C� Application No. /
Judith T. Terry, Town Clerk F �►:�
Town Hall, 53095 Main Road -�-41%; 1 -< $10.00 - Residential
P. O. Box, 1179 '.' . err •: $25.00 - Non•_-Residential
Southold, New York 11971 O ® "��J�
Telephone -..01 `�•
, •'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. _
Fee $109-5-)-
DATE 9-f (0 -";1 -
OWNER NAME: Guo; T. M,eo-toe, •
OWNER MAILING ADDRESS: i10-15- Stfa e„) r�
OWNER PROPERTY ADDRESS: 64 - C\-16.1i - - -
OWNER TELEPHONE NUMBER: MI6^ -110S-322(42
TAX MAP NO. : Section OS J Block LI Lot 17
CROSS STREET: C...10-44., REY1.4
TYPE OF SYSTEM: Septic Tank )( New Existing i)(
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: tty1l iAnuOv/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.)
I ...
Signat e of Ap.licant
RECEIVED BY:
Town Clerk's Office
DATE: Realm
SEP 19 1991
Town Clerk Southold
1
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