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JUDITH T. TERRY Town Hall, 53095 Main Road
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TOWN CLERK p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS trb Southold, New York 11971
y � Fax (516) 765-1823
MARRIAGE OFFICER O ®�
_',,0 /D 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. 3124-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ZIERAN, DONALD
Mailing Address 1 55 MILL CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 55 MILL CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1513
Tax Map No. section 135.00 block 3 lot 24.000
Cross Street GROVE ROAD
Date Of Last Pump Out 0/00/88
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK iC��FF�(�•
Town of SoutholdC'Qcf'- Application No. 3/0.,(..) .
Judith T. Terry, Town Clerk "' . '-
Town Hall, 53095 Main Road - _; -4 $10.00 - Residential
p. O. Box 1179 c 3 KAW 5. $25.00 - Non-Residential
Southold, New York 11971 O ®. $
Telephone 0 ��� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
Fee $
DATE
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OWNER NAME:
OWNER MAILING ADDRESS: 5.5*-- /I/4L Z€f4 'r
®4/ '.0Z,b r ,P �- /17 7/
OWNER PROPERTY ADDRESS: �� „
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block 3 Lot -
CROSS STREET: ,�'p/f, p 1
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool !/ New Existing LZ
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.)
Signature of Applicant
RECEIVED BY: _ £
Town Cler 's Office
DATE: Z° / !�
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