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meq ; . y, x Town Hall, 53095 Main Road
',•'', , P.O. Box 1179
�� At-o �� Southold, New York 11971
JUDITH T.TERRY m . TELEPHONE
, (516) 765-1801
TOWN CLERK
REGISTRAR 01 VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 629-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New _ Existing X
Name Of Owner RUTH D. AND EUGENE OLIVA
Mailing Address 1 BOX 189
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 615 NARROW RIVER ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2441
Tax Map No. section 26. 00 block 3 lot 8. 000
Cross Street KING STREET
Date Of Last Pump Out 0/00/00
Issue Date: 2/26/88 Judith T. T ry - • -
Southold Town Clerk
- (TOWN SEAL) ,
OFFICE OF THE TOWN CLERK cOFO(,r�'- i
Town of Southold �� CQ Application No. 0
Judith T. Terry, Town Clerk ' *%‘'
Town Hall, 53095 Main Road , Residential
P. O. Box 1179 cn ' Non-Residential
Southold, New York 11971 O' ` R`ra r $
Telephone "°,( Y►`a,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
-
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE/ l E-
- J
OWNER NAME: AI 9 n 1q . 04 1)
OWNER MAILING ADDRESS: a ) g 9'
1Dr1&41T ,Q),y_, J )gyp 6- 7
OWNER PROPERTY ADDRESS: ‘Ac'—tea pa-.0 ‘4,07.2) 1,44".-
-
,y ) 1,444".-
OWNER TELEPHONE NUMBER: gal 3 f c 'I/
TAX MAP NO. : Section o Block 3 Lot I
CROSS STREET: 1 Y?1 91--e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ✓
Residential "✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4/g.
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.)
nt.u.
Signature o pplicant
•
RECEIVED BY:
Town Clerk's Office
DATE: - - -
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