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Town Hall, 53095 Main Road
,$ P.O. Box 1179
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OFFICE OF THE TOWN CLERK 0S\FFOGr -
Town of Southold � L0 Application No. / '-
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road ' - "'':
P. O. Box 1179 cn ttr rN ` $25.00 - Non-Residential
Southold, New York 11971O�•J��
Telephone *Q( , y1 •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION ,
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /v•r
` DATE 47(.2--°/F
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OWNER NAME: 1-; L k L. vvl co tRs. �r
OWNER MAILING ADDRESS: 00 X /•'I '( e4„,_1(e.A.i to
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OWNER PROPERTY ADDRESS: -7' ( gi
OWNER TELEPHONE NUMBER: 74k,— S‘
TAX MAP NO. : Section 1 ( 03 Block j,' Lot I (
CROSS STREET: IJ0 120` {
TYPE OF SYSTEM: Septic Tank V New Existing
Cesspool 1/ New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUTS rte-''foi - }mo
r � o /?• 73
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.)
P114--
Signatureatit
RECEIVED BY:
Town Clerk's Office -
DATE: - ;
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, "Unauftorirry nitoraoon or sci alictreoto suav y i :i cv�EtF;i(P' °'y =yt sectian 7209 of thy: Netr York :hla Uchrvt�ti n Capes of thissusurvey map noori,g rhe /and sur, yrr'@ t b t
� � seal or embossed 'eaj shall not ba ronsiderc>d to Ee� o valid co,9},t. " ,e,
a or c,,t lied,ons indicated hereon shall tzar ordy tq v�
yj ae',on For 'whom the survey IS prepared,and on hisz r_ i i
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Nile rnmpon governmental YltiPl, dfit i, l °'t
Y• 8 al agency and lanchng eratttuttn; ?;,*'zJ t"
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or cart;f�catIran> institution. C'q.ir,,1t�".,3.
P s,hsa ;a oras not trnnsfrerable Co additional wstit. '-'3a r=;. I.
q' ni owners
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