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1 Town Hall, 53095 Main Road
+^ P.O. Box 1179
we, � �� Southold, New York 11971
JUDITH T.TERRY _ 00. •
TELEPHONE
rowri CLERK4.- (516)765-1801
REGISTRAR Oh VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 902-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WHITROCK, KEVIN
Mailing Address 1 BOX 809
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 550 PRIVATE ROAD 17
Property Address 2 CAMP MINEOLA
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4463
Tax Map No. section 123.00 block 6 lot 20.000
Cross Street CAMP MINEOLA ROAD
Date Of Last Pump Out 0/00/00
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Issue Date: 11/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�FFO(K '-
Town of Southold , Application No. 9
Judith T. Terry, Town Clerk i r� f
Residential 1,7
Town Hall, 53095 Main Road
P. O. Box 1179 to '' � `' Non-Residential
Southold, New York 11971, e, �0�
Telephone ./ *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee ,$ /0 "
DATE /0 /27.4
OWNER NAME: Ke_Vi I)) th(a(
OWNER MAILING ADDRESS: 10-K U® q
OWNER PROPERTY ADDRESS: 550 RocJ 17
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OWNER TELEPHONE NUMBER: Act6
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TAX MAP NO. : Section Block 6 Lot 0
CROSS STREET: c)C 10,, R.„aC( 17
TYPE OF SYSTEM' Septic Tank New Existing
Cesspool New - Existing
fisting ,
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: g
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: , �� /
o er 's i�ffice
DATE: /07:-)17/
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