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JUDITH T. TERRY �� y� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS °-InSouthold, New York 11971
MARRIAGE OFFICER _ Fax (516) 765-1823
421 ,,,to 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. 1685-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner O'NEILL, EDWARD AND SHARON
Mailing Address 1 P. O. BOX 441
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 3600 DELMAR DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-9345
Tax Map No. section 125.00 block 4 lot 17.000
Cross Street EMMA DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�\\FF�(�•I��
Town of Southold % .. C,Q • Application No. /
Judith T. Terry, Town Clerk '?_�i! �, $10.00 - Residential �(
Town Hall, 53095 Main Road `�
P. O. Box 1179 v' 4 ~::. $25.00 - Non-Residential
Southold, New York 11971 O ®_ ��`�
Telephone .o.( *".
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / �I5
Fee $
DATE
OWNER NAME: �C.1CJ0,U71 tJ�j'�'- L } 01 / / � •
OWNER MAILING ADDRESS: p(2) �� 4//
OWNER PROPERTY ADDRESS: [Q O oz_.)
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OWNER TELEPHONE NUMBER: q3 k,73
TAX MAP NO. : Section /4249, 0Block /941, 690 Lot 9/ 7, C 0
CROSS STREET: a , - ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 7\ New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: R 0
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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 ASI. cant
RECEIVED BY: ._�i':►f4;:,�_ /
iwn` I-r s Of ice
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DATE: • �Y/ /7/
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