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JUDITH T. TERRY '' Town Hall, 53095 Main Road
TOWN CLERK ,' ci P.O. Box 1179
REGISTRAR OF VITAL STATISTICS q Southold, New York 11971
MARRIAGE OFFICER ‘c0 44 Fax (516) 765-1823
® �! 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. 1913-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NORKLUN, RICHARD E.
Mailing Address 1 800 PRIVATE ROAD #21
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 800 PRIVATE ROAD #21
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1383
Tax Map No. section 78.00 block 9 lot 35.000
Cross Street NORTH BAYVIEW EXTENSION
Date Of Last Pump Out 0/00/82
Issue Date: 5/28/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK oS\\FFOC,I'
Town of Southold �� QG Application No./':11-3
Judith T. Terry, Town Clerk . y
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Town Hall, 53095 Main Road $10.00 - Residential{ x
P. O. Box 1179 4 `1- _ � $25.00 - Non-Residential
Southold, New York 11971 0 e= 0��`
Telephone _ .( •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
1 APPLICATION
") for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Yh y / f ��
OWNER NAME: p1CiticYd ET A/01-2 -Cti
OWNER MAILING ADDRESS: BOO P)')114;1"-f._
So-0ho1c4 A / 1l �f
OWNER PROPERTY AtDRESS: g '�
OWNER 'TELEPHONE NUMBER: •&l&) 7/40/6)-'13-73
TAX MAP NO. : Section 7? Block Lot 26-
CROSS STREET: /V.v EIVTe4762.07/1
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ✓
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 025" net Ay )
98'�
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.)
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Signature of Applicant
RECEIVED BY:
Town Clerk' iVID
DATE: MAY 2 ? ' ,
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Town Clerk Southard
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