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OFFICE OF THE TOWN CLERK ' •c���;'�(� „`
Town of Southold ,� � • 4.0, •
Judith T. Terry, Town, Clerk rz , %
Town Hall, 53095 Main Road a ;
P. O. Box 1179
Southold, New York 11971
Telephone Ol Alt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3 Residential XXX
Fee $
Non-Residential
•_10 . 0 0
Septic Cesspool XXX
NAME OF OWNER: John B. Ulp •
OWNER MAILING ADDRESS: 2595 Wells Avenue, P .O . Box 294
Southold, New York 11971
OWNER PROPERTY ADDRESS: same
OWNER- TELEPHONE NUMBER: 765-3758
TAX MAP NO. : Section 070 Block 4 Lot 17
•
CROSS STREET: Jernick Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XXX New Existing XXX
Residential XXX Non-Residential
DATE OF PREVIOUS PUMP-OUT:? ? 7/24/86
Judith T. Terry
Southold Town Clerk
DATE: August 15 , 1986
(TOWN SEAL)
L
itS aro.
OFFICE
OFFICE OF THE TOWN CLERK oc0FOUr##--
Town of Southold �� } CQG Application No.
Judith T. Terry, Town Clerk
=G V Residential LV
Town Hall, 53095 Main Road a -
P. O. Box 1179 � *` e 'moi � Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / Z7!�
DATE ?// 2_/
�6
OWNER NAME: \ref A v`
.2p
OWNER MAILING ADDRESS: i9 'X 2— iee-) i5 AVe"---yc-((7 /"'ijjA/
OWNER PROPERTY ADDRESS:2j 9J/ Ul )J5 A !-' °fee•/ Z-SIO/J/V)/
OWNER TELEPHONE NUMBER: 7 2 7 a
TAX MAP NO. : Section 077 " Block Lot / 7
CROSS STREET: Tamil/ 11 ( (/'1 '� L 2 h t!
TYPE OF SYSTEM: Septic Tank 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
of distance, approximately, to building and closest road.)
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Signature of A plicant
RECEIVED BY: .�`►1�/�. d� p//
•wn er 's I fice
DATE: 1 ��
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�° JOHN ' E,, AND EDITH R. ULP
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'� S O U T -lbt....D, N.Y.
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� ! '� SE SECTION 7209EY IS A VIE AYORK OFITIOri
EDUCATION OF THE NEW YORK STATE
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