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�.: Town Hall, 53095 Main Road
;it P.O. Box 1179
_ 40I i' Southold, New York 11971
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JUDITH T.TERRY y '®. , � FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1452-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VERITY, HELEN M.
Mailing Address 1 865 NAKOMIS ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 865 NAKOMIS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3723
Tax Map No. section 78.00 block 3 lot 26.000
Cross Street HIAWATHAS PATH
Date Of Last Pump Out 0/00/70
Issue Date: 5/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 't-kffo(l '
Town of Southold QC� � Application No. l �
Judith T. Terry, Town Clerk . ,
* $10.00 - Residential
Town Hall, 53095 Main Road r.}..i; "�
P. 0. Box 1179 _; ='rT •`-r/ $25.00 -$25.00 - Non-Residential
Southold, New York 11971
Telephone �(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLDWASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE A3 / 7 b
OWNER NAME: ' ` V •
OWNER MAILING ADDRESS: J/
, 11 ) �.d , //q 7/
OWNER PROPERTY ADIDR_E.SS: ` �j/LLGyr�i Pa
. . � � i / 9 --�
OWNER TELEPHONE NUMBER: 7/S' — 7L
TAX MAP NO. : Section-11-3 --7/6 Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool � New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6
�
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.)
(24 {//
Signature of Applicant (y
RECEIVED BY: c=� % / /
!• . n C/e2: S.—office
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DATE: 7 '
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