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} Town Hall, 53095 Main Road
J' 3 P.O. Box 1179
`. i'� Southold, New York 11971
JUDITH T.TERRY = _4f0®� TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 911 -R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner VANDERBECK, ROBERT W.
Mailing Address 1 2775 WEST CREEK AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2775 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5895
Tax Map No . section 110.00 block 5 lot 4. 000
Cross Street DICKS POINT ROAD
Date Of Last Pump Out 0/OQ/00
Issue Date: 11 /09/88 v Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c0FO(,r
Town of Southold A 4. C / l(
�, „ r,•- .� QG'_, Application No.
Judith T. Terry, Town Clerk �� � 41I�`. * r/
t.; ,< l Residential
Town Hall, 53095 Main Road, . F P. O. Box 1179 cr3 r-41. W.0 Non-Residential
Southold, New York 11971
Telephone -7/ t 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /1/`7 —4
OWNER NAME: I4A4J
OWNER MAILING ADDRESS: 27 C//G2r & 4 -
OWNER PROPERTY ADDRESS: 6:7ic}.,Cl --
OWNER TELEPHONE NUMBER: --
TAX MAP NO. : Section / / d Block 6 Lot
CROSS STREET: /c//S ip®fi7— ROAD
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool l// New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: /T crt
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.)
4
P/- 4s c&— o
Signatur- of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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