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JUDITH T. TERRY �' Town Hall, 53095 Main Road
TOWN CLERK � " • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS t4 Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
s,���!� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1724-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MU I R, JILL
Mailing Address 1 P. O. BOX 241
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 265 RACKETTS COURT
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-27811
Tax Map No. section 17.00 block 6 lot 9.001
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/12/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF THE TOWN CLERK c3VFF ��
Town of Southold �� CQ Application No.
Judith T. Terry, Town Clerk " ,fi J►
Town Hall, 53095 Main Road -< $10.00 - Residential )1
p. 0. Box 1179 cr3 ; $25.00 - Non-Residential
Southold, New York 11971 4 ��`
Telephone _°.1 * '
-- (516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /fo /qf
OWNER NAME: VI
OWNER MAILING ADDRESS: `?O, &x o& i
0,ki c.0T( G .Y. 11 qS'l
OWNER PROPERTY ADDRESS: ai‘ Ck -t-t-.r Cts--r-
ORi•EV-r, Ml l 1 qr).
OWNER TELEPHONE NUMBER: - g Y
TAX MAP NO. : Section O)). Oc Block Ob• 00 Lot Oiq. so )
CROSS STREET: m IJ ggsA-b CKT-• .ZS�
TYPE OF SYSTEM: Septic Tank / New Existing V7
Cesspool f - New Existing v/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: UI/K►jjo\iJpJ fito.J3ABL,y MANN YOW )
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.) -
.tfkicfL,
(STture of Applicant
RECEIVED -BY:
Town Clerk's Office
DATE:
JUL 12 1991
TOM Mark Southold
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