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grA �� Town Hall, 53095 Main Road
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W ' ®�' ' P.O. Box 1179
44, Southold, New York 11971
JUDITH T.TERRY ��� ii" 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. 1487-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WESTEE, ALPHONS AND MARGARET
Mailing Address 1 P. O. BOX 428
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 2780 PECONIC BAY BOULEVARD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-8327
Tax Map No. section 128.00 block 6 lot 23.000
Cross Street WENDY DRIVE
Date Of Last Pump Out 0/00/84
Issue Date: 6/18/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK .0 o •�• !
Town of Southold �� _ _. sol-• Application No. /487
Judith T. Terry, Town Clerk . 5., -t1) $10.00 - Residential
Town Hall, 53095 Main Road
p.
0. Box 1179 .{,' 0
-:Y ...�.._-•;�� � $25.00 -
Non-Residential
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Southold, New York 11971 ,
Telephone �� 4 %.°‘0-
(516)
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
T T
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee s/ € e
DATE &Nz //G/ /•
/ /D
'OWNER NAME: 4010//6.4/.5 7')11)// l ��' sisEg •
OWNER MAILING ADDRESS: �,L�GoQ/�/ C ,�, �//" . �Q •
X/4G?,.Q,4�. N 7 /<
OWNER PROPERTY ADDRESS: oZ'7 7P, /r-Z ,e3/51'Z P.
.G4k1,07L> "1/.Y / y
OWNER TELEPHONE NUMBER: @X) f P / doZ
TAX MAP NO. : Section r Block ‘ Lot D.e,?
CROSS STREET: NW 1,4/27/W7 !/iC/U�' ( A7 ) 7)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential // Non-Residential
DATE OF PREVIOUS PUMP-OUT: A/S LA/ //y Pie j! Gf�iii�0 (Nt j/9O
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 ler 's Office
DATE: L. `La+►
JUN 1 8 1990
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