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OFFICE OF THE TOWN CLERK ' c31
Town of Southold %;:z;
CJudith T. Terry, Town, Clerkw' `.
Town Hall, 53095 Main Road �. _
P. O. Box 1179 cr3 '' - ' .
Southold, New York 11971 �
O '` � '`
Telephone _ ,( Agit 14%
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4 Residential xXX
Fee $ - 10 . 0 0
Non-Residential
Septic Cesspool XXX
NAME OF OWNER: Fdwnrd & Viola Mocblcch
OWNER MAILING ADDRESS: P 0 . Box 843
Orient . New York 11957
OWNER PROPERTY ADDRESS: 235 Douglas Road
Orient , New York 1957
OWNER, TELEPHONE NUMBER: 323 -2542
TAX MAP NO. : Section 26 Block 3 Lot 4
CROSS STREET: King Street
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XXX New Existing XXX
Residential XXX Non-Residential
DATE OF PREVIOUS PUMP-OUT: unknown
Judith T. Terry
Southold Town Clerk
DATE: August 15, 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FU(,-;-,
Town of Southold �� . OG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ..4% -) Residential t/
P. O. Box 1179 cn t •‘.$.`' Non-Residential
.._.
Southold, New York 11971 O � µtyY_4 .;:
Telephone 4Q,1,4%--
d [ #.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
a Fee $ /•/). o
DATE
OWNER NAME: p V/ / [ (J S' �L. lei/—
OWNER MAILING ADDRESS: p0. Qo . q3
OV, r- f",V // 9r7
OWNER PROPERTY ADDRESS: v2 35- 00‘)/--/§11'
e le/i/T- ff/ /i r,s7
OWNER TELEPHONE NUMBER: 3 -2-3—
TAX
2-3TAX MAP NO. : Section alp Block 3 Lot
CROSS STREET: Aillif C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (//UAA/aix/At C �pP' S J
LOCATION MAP: Must be attached hereto before permit may be issued. j
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY: 4
!„� 1/
Cl:rk's Offi•e
DATE: eib, .f
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