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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3439-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner THORP, EDWARD A. AND VIRGINIA
Mailing Address 1 12 NORCROSS STREET
Mailing Address 2
City St Zip ROCKVILLE CENTRE NY 11570-0000
Property Address 1 1655 OLD ORCHARD ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-536-7982
Tax Map No. section 31 .00 block 15 lot 4.000
Cross Street NORTH LANE
Issue Date: 2/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1 U ;, „ „i i.•
OFFICE OF THE TOWN CLERK
Town of Southold , � CQG Application No. 359?
Judith T. Terry, Town Clerk - ., y .
Town Hall, 53095 Main Road " a . - < $10.00 - Residential
' P. 0. Box 1179 v' $25.00 - Non-Residential
Southold, New York 11971- • , O "its $
Telephone `�►�,
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
-
Fee $ ��'��' ., W , ,• -- ; - - - . .. - -
- ..._ - __ ..-
Pe DATE/w
OWNER NAME: e---NyAkt. e_G AI IA - 77-4-0��-
OWNER MAILING ADDRESS: 1a.. NORCROSS ST
RC) CT Y115.7o
OWNER PROPERTY ADDRESS: /632-5 31-13 O RCH cj j K,D
ASr Mel ON
OWNER TELEPHONE NUMBER: C.5-
TAX MAP, NO. : Section 03 I Block 15 Lot Lit-
CROSS ,STREET: NC)yz•-rui " Lq-AfL
TYPE OF SYSTEM: .Septic, Tank _ New Existing
, Cesspool{ V . New Existing I _
Residential Non-Residential
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.)
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Siyature of Applicant
RECEIVED BY: •
- . . ' Town Clerk's Office- - ,
•
DATE: " • ,
4
1,6
•
031-15-4
,i
Edward A & Virginia Thorp
12 Norcross St'
Rockville.Ctr NY '11570-1925