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Town Hall, 53095 Main Road
P.O. Box 1179
__ l®1 Slit ��• Southold, New York 11971
JUDITH T.TERRY -. ���� TELEPHONE
TOWN CLERK (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. 797-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner WENK, NORMAN B. III & WIFE
Mailing Address 1 P. O. BOX 98
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 415 SOUTH LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0315
Tax Map No. section 31. 00 block 16 lot 2.002
Cross Street OLD ORCHARD LANE
Date Of Last Pump Out 0/00/00
Issue Date: 8/25/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.SFU(,'�'= •
Town of Southold � `ol'; Application No.
Judith T. Terry, Town Clerk 4, t4,,5
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Town Hall, 53095 Main Road '` lk =4. Residential
P. O. Box 1179 v' :t 11.;4*- tri ��' Non-Residential
Southold, New York 11971 ®
Telephone ,( z
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O • O
DATE ilitAji 13, /172
OWNER NAME: M1 . 1)1(c Alorm. -`- MJt't---
OWNER MAILING ADDRESS: Po goy ?e?
ivy , /JL1 llg3 /
OWNER PROPERTY ADDRESS: qJc kg, rad it
OWNER TELEPHONE NUMBER: 1477—c 315®
TAX MAP NO. : Section 3 Block I6 Lot d° •�
CROSS STREET: Old r- A-tti d
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1-0-1-1- Y rigg
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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Sign ture of Applicant
RECEIVED BY:
own Clerk's Office
RECE
DATE:
AU2r1G
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