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fes' A f Town Hall, 53095 Main Road
® - P.O. Box 1179
EvAs �•,i' Southold, New York 11971
JUDITH T.TERRY ` '%� '''� I• FAX )765-1823
TELEPHONE16)765-1801
TOWN CLERK
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. 1441-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WHITE, EDMUND AND AUDREY
Mailing Address 1 695 NAVY STREET
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 695 NAVY STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3584
Tax Map No. section 25.00 block 3 lot 20.000
Cross Street ORCHARD STREET
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .S�FF�(/I' '-
Town of Southold % x... C'� Application No. / 4 /
Judith T. Terry, Town Clerk . =t 4 -
K.
Town Hall, 53095 Main Road `_ :' $10.00 - Residential
p. O. Box 1179 u" let tf__,x: , i �` $25.00 - Non-Residential
Southold, New York 11971 O " :; 14/(''
'��
Telephone .OI••
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERA ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
•
DATE a l aO 1 `fd
OWNER NAME: rriU01 A-OcVE,Ci.) O1TIE •
OWNER MAILING ADDRESS:( ? 5 1JM\b( e
OQ) i a
OWNER PnOPEnTY ADDRESS: V9i aur Ste€ 1
•
ORI c �- N� )toe ) 19.57
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section cls.--S Block 3
CROSS STREET:_ 1 - I Sr ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (a1 0'
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.)
A'11/ /I
Signa ure of Applic-nt-
RECEIVED BY:
Town Clerk's Office
DATE:
2,75./ 2T.
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