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JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK
® =5 Gi Southold, New York 11971
REGISTRAR OF VITAL STATISTICS R�
MARRIAGE OFFICER ‘,30eth C) 4
,, Fax (516) 765-1823
® �- 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. 1824-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TROWNSELL, CHARLES S.
Mailing Address 1 122 CRABAPPLE LANE
Mailing Address 2
City St Zip SYRACUSE NY 13219-0000
Property Address 1 OAK AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 315-488-4424
Tax Map No. section 77.00 block 1 lot. 6.000
Cross Street CEDAR AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 12/19/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
j
OFFICE OF THE TOWN CLERK S0FO(,r ' c
Town of Southold �� -. c. Application No. goy
Town Clerk
Judith T. Terry, ��
. $10.00 - Residential
Town Hall, 53095 Main Road "`
P. 0. Box 1179 cnt4:1" $25.00 -t .` Non-Residential
Southold, New York 11971 O � �0�
Telephone .( �►
(516) 765-1801 •
TOWN OF SOUTHOLD
' 1
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
ti
DATE 2
OWNER NAME: C`JAR i-1 s i (�•Owi✓S%//
OWNER MAILING ADDRESS: ja, a 'v2Ab �i � ).,, `4 `/
S/J A c V'J/ /1/y
OWNER-PROPERTY ADDRESS: CA k, AVi
OWNER TELEPHONE NUMBER: 3 J,,l`-- Vert— V'/ a V
TAX MAP NO. : Section /000 Block 7 7 Lot / —
CROSS STREET:
TYPE OF, SYSTEM: Septic Tank - New Existing
Cesspool X New Existing 4.
Residential X 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
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY: - -
Town 'Clerk's Office
DATE:
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