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Town Hall, 53095 Main Road
®,,•, 't 44 P.O. Box 1179
-_ %� W":00 Southold, New York 11971
JUDITH T.TERRY %.,zir�i`�' 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. 1465-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OYSTERPOND HISTORICAL SOCIETY
Mailing Address 1 P. O. BOX 844
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 VINCENT STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2480
Tax -Map No. section 25.00 block 3 lot 16.001
Cross Street FLETCHER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
c0FoUr
Town of Southold � .,._. CQ = Application No. I7CeS
Judith T. Terry, Town Clerk '4 Wit•
Town Hall, 53095 Main Road ��{ ��_` :� 10.00 - Residential
P. O. Box 1179y�vw� _
u-� -`z�=� ��='= '� : $25.00 Non-Residential
Southold, New York 11971 '4?
'yl $- -
Telephone :ol 44 %0, •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 9®
OWNER NAME: 'r cao �,d 17`,.s�o Y;C �, ` ac
OWNER MAILING ADDRESS: kTJ
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OWNER PROPERTY ADDRESS: \t1c - c
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• OWNER TELEPHONE NUMBER: 2.`76
TAX MAP NO. : Section Block Lot
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CROSS STREET: . , L 1-r___•( dQ-_ Si
TYPE OF SYSTEM: Septic Tank e New Existing r✓
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: a �4 I
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
5tA.o`el of distance, approximately, to building and closest road.)
f Signat, Applican
RECEIVED BY:
Town Clerk's Office
DATE:
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