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JUDITH T. TdRY �� j` , � Town Hall, 53095 Main Road
TOWN CLERK ;( P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ® r, r71 ,, Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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Telephone (516) 7651801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1714-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WENDELL, ROBERT W. AND JEAN
Mailing Address 1 1020 GLEN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1020 GLEN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1335
Tax Map No. section 78.00 block 2 lot 28.000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'C3\\VMir
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Town of Southold �� CQG' , Application No. , 7/Y
Judith T. Terry, Town Clerk �^
Town Hall, 53095 Main Road -< $10.00 - Residential
P. O. Box 1179 u3 'Z }43 r $25.00 - Non-Residential
Southold, New York 11971 O•
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Telephone _ ,( '�O�''
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ r/'
DATE t47-1q4
OWNER NAME: 7,� (�/1 //J' CL7
') M 74479-
OWNER MAILING ADDRESS: pc?-0 (v,/_-�t/41/j
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: 2Cd-> r33.1/
TAX MAP NO. : Section 1 7 Block Lot
CROSS STREET:•
TYPE OF SYSTEM: Septic Tank New Existing •
Cesspool � New Existing `�—
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
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Signature of Applicant
RECEIVED BY: -
own Clerk's Office
DATE: k"' 7 77/ 00'
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