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Qrb® �� `^ FYI '1 Town Hall, 53095 Main Road
P.O. Box 1179
47Q
'-s1 •••• Southold,New York 11971
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JUDITH T.TERRY _ (00 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. 1485-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WALDRON, ROBERT E.
Mailing Address 1 2980 OLE JULE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2980 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8756
Tax Map No. section 122.00 block 4 lot 17.000
Cross Street NEW SUFFOLK AVNENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/15/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •"• ''
OFFICE OF THE TOWN CLERK .SOMar
"
Town of Southold � ._ CQ,"" Application No. / 4-Pce
Judith T. Terry, Town Clerk ozsc : _ 10.00 - Residential
Town Hall, 53095 Main Road s $
P. O. Box 1179 cr3 ' 1--z -;7Y ; $25.00 - Non-Residential
Southold, New York 11971 O �yst '' 0���`,
Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l C7
DATE (di3APb
'OWNER NAME: ois)Q..F . \,la*POwn
OWNER MAILING ADDRESS: SZa$IZ)
ccc� ` v c.K< JrI _ I I 5 0--
OWNER PROPERTY ADDRESS: So.•r,..a_ os a\eyv•�..r
OWNER TELEPHONE NUMBER: 5 1 - 2.S -salvo
TAX MAP NO. : Section /1 Block 2 Lot I �1
CROSS STREET: OsJgvt svcPat iC
TYPE OF SYSTEM: Septic Tank New Existing x
Cesspool New - Existing
Residential N. Non-Residential
DATE OF PREVIOUS PUMP-OUT: n 3 9 S\CIQ
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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to to
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P� �Q SURVEY OF
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9. ` 't9� a Title Association.
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ell CERTIFIED TO.* -r 0 L A.D,s -
.o es O$:Ng'�0 NORTH FORK BANK AND T ���� NGS�p%
q �� SS l ROBERT WALOf ON, JR. ' ' P4i< �� t�
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.g \ 'L a . . IC.NO. 49668
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eP FE c� o S 5 V 15/61 765 - 50 %k.
., P.O. BOX 909
���PF V k_ MAIN ROAD
SOUTHOLD, N.Y. 1197/
87 -842