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JUDITH T. TERRY ate '40Z, f - Town Hall, 53095 Main Road
TOWN CLERK � rL r� s, P.O. Box 1179
REGISTRAR OF VITAL STATISTICSg " 7 4� Southold, New York 11971
OFFICER � Fax (516) 765-1823
MARRIAGE
® ��t Telephone (516) 765-1801
4131
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1781-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner THOMA, GRACE D.
Mailing Address 1 P. O. BOX 585
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2275 HIGHLAND ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7504
Tax Map No. section 102.00 block 8 lot 8.000
Cross Street SPUR LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF THE TOWN CLERK •cuFFO(,( -
Town of Southold ACQ - Application No. __Z
Judith T. Terry, .Town Clerk �£ —
Town Hall, 53095 Main Road
$10.00 - Residential
p. O. Box 1179cnt � " ; $25.00 - Non-Residential
Southold, New York 11971 O 0`:1 •kz$
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Telephone _ j 1
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. l 5f
Fee $ /O — r
DATE /0/81/7/
OWNER NAME: me, cref}eE . �o
OWNER MAILING ADDRESS: / O , 'joX -
d c,-%G#O LL,c, AZ/ , /(9 3.-
OWNER PROPERTY ADDRESS: tiv7. Al!C'oy/-i✓ ) e,6 ,
Lu,-7--Gi-fO k6, A,/ if 3'
OWNER TELEPHONE NUMBER: pi-7-74-04
4-04
TAX MAP NO. : Section / 0 Block SY Lot e
CROSS STREET: $'PcArQ ti{l�E
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool .1/ New Existing 1/
Residential t/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: A4A/E—
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.)
A 2
Signature of Applicant
RECEIVED BY: Ai(
Town Clerk's Office
DATE: / 0119(
__________
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