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417,04JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK
C=I
rS}9 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS •3 Southold, New York.11971
MARRIAGE OFFICER • Fax� Fax (516) 765-1823
�,y®� . . �� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2014-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TRENT, MARTIN
- Mailing Address 1 4390 ORCHARD STREET -
Mailing Address 2
City St Zip ORIENT NY 11957-0000
" Property Address 1 4390 ORCHARD STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2690
Tax Map No. section 27.00 block 3 lot 7.006
Cross Street NARROW RIVER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 12/03/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICEYOF THE TOWN CLERK �FFO (�
• Town of Southold ,&1% �CQG' Application No.o�d /
•
Judith T. Terry, Town Clerk a;
Town Hall, 53095 Main Road $10.00 - Residential
p. O` Box =1179 - cr' _ • $25.00 - Non-Residential
Southold =.New=York 11971
Telephone = 1
17L-0-0'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE / �-42--'
OWNER NAME: f W 1 f✓ t
OWNER-MAILING ADDRESS: 3`G0 L-/r�Ii e S
fr-
OWNER PROPERTY ADDRESS: SGS,.---c
OWNER TELEPHONE NUMBER: 32,-3- 2� O
TAX MAP NO. : Section Block
� Lot
CROSS -STREET:"-"- ---- { (��V2-� ILc
TYPE OF SYSTEM L' Septic'Ta•nk-= = ✓- -- -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 (o_v•e)
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY: -
°Town Cler-k''s"Office
DATE:
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