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JUDITH T. TERRY 1 _ Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ?®� O �� Fax (516) 765-1823
__ �® . Telephone (516) 765-165-1
801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2000-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NORKELUM, AGNES
Mailing Address 1 209 KNAPP PLACE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 209 KNAPP PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1337
Tax Map No. section 34.00 block 3 lot 11 .000
Cross Street BAILEY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/28/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �COFU(,(-��'
Town of Southold A CQ ' Application No. c. OOO
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road . -4 $10.00 - Residential
p. O. Box 1179cr3x .> �` $25.00 - Non-Residential
Southold, New York 11971. O •, r J
Telephone 04
��I
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
' for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: Agnes Norkelum
OWNER MAILING ADDRESS: 209 Knapp Place
Greenport, L. I.
• OWNER PROPERTY ADDRESS: 209 Knapp Place
Greenport, N. Y.
OWNER TELEPHONE NUMBER: 477-133?
TAX MAP NO. : Section Block Lot
CROSS STREET:
•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing XX
Residential XX Non-Residential
•
DATE OF PREVIOUS PUMP-OUT:
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 Applicant
RECEIVED BY:
f, tark's Office -
DATE: OCT Pi
Town CM Mord