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Town Hall, 53095 Main Road
o �.• P.O. Box 1179
�__ �e��,�' Southold, New York 11971
JUDITH T.TERRY -- ,izi,/�'�� FAX(516)765-1823
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. 1553-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner O'DEA, PAUL G.
Mailing Address 1 435 BAY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 435 BAY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6811
Tax Map No. section 116.00 block 2 lot 9.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/75
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OF.1'C1 :'OWN CLERK . �c���F�(K.
ToW�; Southold � , C�G�_ Application No. /S-6-3
Judith T. Terry, Town Clerk Wit` L+. _ � $10.00 - Residential
Town Hall, 53095 Main Road a ^� .
P. O. Box 1179 (fl ` r= ; i
•,•� $25.00 - Non-Residential
Southold, New York 11971
Off.•••
Telephone _0j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE - I
OWNER NAME: �� C5‘; 0 \DEA
•
OWNER MAILING ADDRESS: ?�� (7/y \ C-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: J/ `v �( 7j - L, g )
1 _
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New. Existing
Cesspool New Existing
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: (\A `( 6--(6e)
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.)
1 Z C'—c)Ou\
Signatu f Applicant
RECEIVED BY:
Town Clerk's Office
•
DATE:
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