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JUDITH T. TERRY '' 1 Town Hall, 53095 Main Road
TOWN CLERK ® azy e' P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �." � Fax 516 765-1823
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MARRIAGE OFFICER l% ( )
�! Telephone (516) 765-1801
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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. 1642-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WORTIS, MICHAEL ET AL.
Mailing Address 1 7367 RIDGE DRIVE
Mailing Address 2 BURNABY B.C.
City St Zip CANADA V5A 1B4 00000-0000
Property Address 1 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5191
Tax Map No. section 86.00 block 3 lot 1 .000 -
Cross Street BAY HOME ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE'OF THE TOWN CLERK c$FULJ1
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Town of Southold Q i C� = Application No../(r,
Judith T. Terry, Town Clerk a' $10.00
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u' r ='?
$25.00 - Non-Residential
Southold, New York 11971 '� '} ��`•
Telephone vjJIXel1‘ •
(516) 765-1801
TOWN OF SOUTHOLD
C SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /
Fee $ /O —
DATE 3 qt
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OWNER NAME: I" ��.a't�Q� LA/ r j Q/� 4& C IVtlo es j'C
OWNER MAILING ADDRESS: 7 3 6 7 OG►e_ 0216
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OWNER PROPERTY ADDRESS: s(J� - �;�b1X: (�!!`c
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OWNER TELEPHONE NUMBER: 6 e - 2-9t• 5 c -z
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Z GS- 5-191
TAX MAP NO. : Section g Block t Lot
CROSS STREET: ) s e-
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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GnrP2pji ,,,� Signature of Applican
- RECEIVED BY:
Cos 0� 1 (ere arc- G
Town Clerk's Office
DATE: -/ 8 - 9 /
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