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OFFICE OF THE TOWN CLERK cvFFOUr •
Town of Southold �� CSG
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179 cn
Southold, New York 11971
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Telephone =,.�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 52 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool XX
NAME OF OWNER: Patricia Zeller
OWNER MAILING ADDRESS: Route 25
Greenport, New York 11944
- OWNER -PROPERTY-:ADDR,ESS: - Route 25
Greenport, New York
OWNER TELEPHONE NUMBER: 516-477-2258
TAX MAP NO. : Section 45 Block . 5 - Lot 1
CROSS STREET: Chapel Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX New Existing XX
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terr!
Southold Town Clerk
DATE: September 19, 1986
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ���FFO
Town of Southold %�-. - CSG'_, Application No.
� �
Judith T. Terry, Town Clerk 4V.-, , y
Town Hall, 53095 Main Road
pa gy k: „ -4 Residential
P. O. Box 1179 cans
�,F� ��A Non-Residential
Southold, New York 11971
Telephone : .( ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 9),.----77,---&
NAME: ja ' "
z 2- -e-
OWNER
OWNER MAILING ADDRESS: / /9 .-'
OWNER PROPERTY ADDRESS: (e---‘67(-}gegX.1-47
OWNER TELEPHONE NUMBER: �/ c777 c - --5--,r
TAX MAP NO. : Section 21 5 Block S Lot /
CROSS STREET: CQ ri-- Cc. -(i
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential - Non-Residential
DATE OF PREVIOUS PUMP-OUT: -,1',-2€ �R.ss_ J
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.)
1111F e-
Signature of Ap• .nt
RECEIVED BY:
Town Clerk's Office
DATE: