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cry . ; Town Hall, 53095 Main Road
�� �$, P.O. Box 1179
�/Ql4 'ri�® r� Southold, New York 11971
JUDITH T. TERRY �����o, //""I'll TELEPHONE
TOWN CLERK (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. 1053-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NORDLINGER, ANNETTA
Mailing Address 1 P. O. BOX 144
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 515 ORCHARD STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6307
Tax Map No. section 117.00 block 5 lot 34.000
Cross Street THIRD STREET
Date Of Last Pump Out 0/00/00
Issue Date: 3/17/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK �FFO(,r/''•
Town of Southold � C� = Application No. //J
Judith T. Terry, Town Clerk r=� tt
Town Hall, 53095 Main Road a `�"etZResidential
P. O. Box 1179 u' c ?, r"3
i • Non-Residential
Southold, New York 11971 O ®
Telephone *0-4- *S/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 9
DATE -2) 1 (c0
OWNER NAME: h 1\P_ �-- o r-A 1I 1`1
OWNER MAILING ADDRESS:--, `f)00 I :"
NC.L0 Noav:es-10
OWNER PROPERTY ADDRESS: 51 I r-ciculf.4
OWNER TELEPHONE NUMBER: 75(1-VD �� {
TAX MAP NO. : Section I 1 1 Block Lot 3 c
CROSS STREET: -114.4.)-(4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential t_ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 2
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.)
eitut:_cs/LL OLS101.4
Signature of Applicant
RECEIVED BY: c/(.2 ro&z)
Town lerk's Of fice
DATE:
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