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JUDITH T.TERRY 1,1�� `€ f, �� • Town Hall, 53095 Main RoadED
TOWN CLERK r P P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ;
" OFFICE OF THE TOWN CLERK 'S��FOL-�
Town of Southold �� C' 3 3-7/OG'�, Appli-Cation No.
Judith T. Terry, Town Clerk .�� yr y :`
-Town Hall, 53095 Main Road ""' $10.00 - Residential
•P. O. Box 1179 cr' ' *} : ' ;' $25.00 - Non-Residential
Southold,,,New York 11971 ` 0 ��`
Telephone 0 ��• 19•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/O,-CSD
DATE 6, — 5 — 5"
OWNER NAME: Sfre}-C&uJE1._{/fE /t DSK-Ocio f7 2
OWNER MAILING ADDRESS: 5/5 E -74i S<R 7 *01-o-I
NEW yeAig i I7 coo 21
OWNER PROPERTY ADDRESS: go LA-K-6 / VC S00-TN
.Sou-r-H-oto . N y I f 9.71
OWNER TELEPHONE NUMBER: (21 2) 7G5 — S SG1
TAX MAP NO. : Section 4.73 '5s7 Block go, -3 - /i- Lot
CROSS STREET: C/-12, PO(N7 ,1 E-11-S-1
TYPE OF SYSTEM: Septic Tank Z New Existing i/
Cesspool New Existing
Residential ✓ Non-Residential
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.)
Signature of Appli t
RECEIVED BY: F'
own Clerk's Office
DATE: AUG 31995
JDwn Clerk Soutwol4
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