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Walsh
SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3495-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner WALSH, CALE AND ROBERT Mailing Address 1 1524 MAEDER AVENUE Mailing Address 2 City St Zip NORTH MERRICK NY 11544-0000 Property Address 1 12115 MAIN ROAD Property Address 2 City St Zip EAST MARION NY 11939-0000 Owner Telephone No. 516-377-0096 Tax Map No. section 31 .00 block 5 lot 3.000 Cross Street Issue Date: 8/16/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) L • .0 OFFICE OF THE TOWN CLERKvOFO Town of Southold �� = Application No. 05- Judith T. Terry, Town Clerk -gs• �i V , ,r"` $1000 - Residential Town Hall, 53095 Main Road . P. O. Box 1179 Az $25.00 - 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 $ /Z" — DATE ` / Uj4: OWNER NAME: �r/� , , i/449_„r 4/ ` .t1►_ .._ OWNER MAILING ADDRESS: /(% i/ 4e4.(; _x� >`. • OWNER PROPERTY ADDRESS: OWNER TELEPHONE NUMBER: 377---d---e9 TAX MAP NO. : Section OLQ ) _DD Block 05. 00 Lot Oaf _OO CROSS STREET: TYPE OF, SYSTEM: Septic Tank NewExisting Cesspool / New Existing Residential 5 Non-Residential 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: - 7 F if • Se,C'41 'a 3, 1 , 0 t\I Pokerl- 1W Pci- E - Parloki , k , 1031 (-04 a113 - ©©6 A , lg 0, YO)- 1-\ou-se \\Nk\6 \<c