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' : �''`� Town Hall, 53095 Main Road
,.�` ``` - -/ P.O. Box 1179
y~•".'���, ,;:i ' r00 Southold, New York 11971
JUDITH T.CLERKTERRY
���I� ` 765-1823
TELEPHFAXONE(5 6)765-1801
TOWNREGISTRAR OF VITAL STATISTICS • OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1045-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WALTERS, LOUIS
Mailing Address 1 BOX 101
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 NORTH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-3421
Tax Map No. section 74.00 block 3 lot 1-.001
Cross Street PECONIC LANE
Date Of Last Pump Out 0/00/79
Issue Date: 3/10/89 Judith T. Terry
Southold Town Clerk -
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKp
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Town of Southold CQ ' Application No.
Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road o sy Residential
P. O. Box 1179 cr3 ; Non-Residential
Southold, New York 11971 oc-", 0 P•45:-:!�O�•�'�
Telephone = 1
(516) 765-1801 .
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for '
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3/47/e7
• OWNER NAME: 1.� v L4 1,5 o.,r 4.'ei Ir" S
OWNER MAILING.ADDRESS: P,, ery., / Co I
1U c r+ 1L, c.. cl- ee.„ o Nr c.c, 111/,‘/ 21 96-e
OWNER PROPERTY ADDRESS: d y jd
I'Vvr4-1A., oe.cL & :., o!v t•e. 1N.�/ JLg5
OWNER TELEPHONE NUMBER: ✓ 4 .. 3 '/c I
TAX MAP NO. : Section 7 Block 3 Lot 4, /
CROSS STREET: ik C o YJ t c- 1... t} Kr E--
TYPE OF SYSTEM: Septic Tank / New Existing,
Cesspool l/ New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9 9
r n Z-77•-may
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.)
10" ‘e)C?,eF
Signature of Applicant
RECEIVED BY:
Town Cle'rk's Office
- DATE:
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