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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T j P.O. Box 1179
REGISTRAR OF VITAL STATISTICS CP Southold, New York 11971
MARRIAGE OFFICER Fax ACV
Fax (516) 765-1823
,y®1 * NW/� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2095-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner O'NEILL, ARTHUR A.
Mailing Address 1 820 SMITH DRIVE SOUTH
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 820 SMITH DRIVE SOUTH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2658
Tax Map No. section 76.00 block 3 lot 21 .003
Cross Street TERRY PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFFICE OF THE TOWN CLERK .cl\f FO(,r
Town of Southold �_ CQ - Application No. C�
Judith T. Terry, town Clerk . ; I �+
Town Hall, 53095 ain Road Y' $10.00 - Residential
P. O. Box 1179 v' ,,.§ ,, `, :
$25.00 - Non-Residential
Southold, New York 11971 OO, f`-*64 -.°"�Oi��'
Telephone .( * '
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE Z li°d/L 9
OWNER NAME: a 'N /L Z_ j9-,' 72 viz /5 _
OWNER MAILING ADDRESS: g-2,0 5,91, /)jp c$'®t
901i 4,0t_4 . lv /lq7 /
' OWNER PROPERTY ADDRESS: OL,
OWNER TELEPHONE NUMBER: 5/G r 7/c"-- 2.1 Sir
76 3 z / 3 TAX MAP NO. : Section /6 Block 3 Lot cg. /. 3
-CROSS STREET: feiejey fl4-c-e
TYPE OF SYSTEM:- -Septic Tank -. - -- New Existing
Cesspool New Existing / ---
Residential 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.)
/;"1"4/-arr
naturepp lc nt
RECIVED_BY: l/0- f.�--� — -
Town Clerk's Office
DATE:
(5--- 7 93
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