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Town Hall, 53095 Main Road
P.O. Box 1179
V® Southold, New York 11971
�� FAX(516)765-1823
JUDITH T.TERRY = %��z�i%'`
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1464-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NEWSOME, JOHN J. JR. & LOIS J.
Mailing Address 1 P. O. BOX 295
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 295 ISLAND VIEW LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1727
Tax Map No. section 57.00 block 2 lot 29.000
Cross Street BAYSHORE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'c�vFFD(,-�''
Town of Southold � X};� C'� ' Application No.7`7/�%
Judith T. Terry, Town Clerk i •xr.n
�":;;: <-. .0 $10.00 - Residential
Town Hall, 53095 Main RoadfrN�3
P. O. Box 1179 73-'35 $� = `mo i $25.00 - Non-Residential
Southold, New York 11971 O,I �J
Telephone lo•�~ 1�� ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER' DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/D. %a J
DATE 2u/4 7' (� /77D
OWNER NAME: i/i/ 17R / /lo/5- .N/ /*_.4.)5c"ky •
OWNER MAILING ADDRESS: P.a. /50)( .r7r .-,LS/,e/p
/yea/ }4a�e,� /(7)1V---
OWNER
(7)1`-"OWNER PROPERTY ADDRESS: 71.1-- v/.e',...) 4/e_
66,eeen/P6x3-- /
OWNER TELEPHONE NUMBER: -/977- (7-✓'
TAX MAP NO. : Section 47 Block Lot 1.1
CROSS STREET: I34s/S//o, p /roil?
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: �7;%-r /s 17---//e-5:
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.)
onature of Applican
RECEIVED BY: .
!e ' rk's Office
DATE: MAY 1 i s;,.�{
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