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li§ ® Town Hall, 53095 Main Road
cf./ j, / P.O. Box 1179
� 9 Southold, New York 11971
JUDITH T.TERRY - i"��rTELEPHONE
.Avow � (516) 765-1801
TOWN CLERK
REGISTRAR 01 VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 628-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner ROBERT AND DOROTHY YOUNG
Mailing Address 1 P.O. BOX 658
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 300 NORTH ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-9772
Tax Map No. section 40. 00 block 1,0 lot 8. 000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/26/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK . 'SVFFO(,r.�=
Town of Southold �� w". CQ ' Application No.
Judith T. Terry, Town Clerk • .�Jo' i .
Town Hall, 53095 Main Road a ,z -` f° } Residential
P. O. Box 1179 cra ti - •
_ ' �, ,�, �i � Non-Residential
Southold, New York 11971 O ®. ' �•`�
Telephone : . r se
( �•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. l0(467
Fee $
DATE
OWNER NAME: Robert l
aro1 l /lockno-
.OWNER MAILING ADDRESS: Soo /or/i //Foal,l, RO. 8oX 65-S
•
G reel yacr /t4A l rbc //94 .
OWNER PROPERTY ADDRESS: As Move
OWNER TELEPHONE NUMBER: fjc rf 72,
i.stT, .0 I Coo
TAX MAP NO. : Section p/fO. CO Block 0/. 00 Lot 0OS, 000
CROSS STREET: k-cr Mt
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.) •
.a5ro-A41 / )70.44-17:19 .
Siiature of 4plicant
RECEIVED BY: -
Town Clerk's Office _
DATE: .-
1 /
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