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Town Hall, 53095 Main Road
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P.O. Box 1179
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�, Southold, New York 11971
JUDITH T.TERRY '__ �. i�' TELEPHONE
TOWN CLERK � (516)765-1801
REGISTRAR 01 VITAL S rATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 916-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROWN, ANNIE
Mailing Address 1 900 MASON DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 900 MASON DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7298
Tax Map No. section 1011.00 block 7 lot 4.000
Cross Street HAYWATERS DRIVE
Date Of Last Pump Out 0/00/78
Issue Date: 11/10/88 Judith T. Terry
Southold Town Clerk
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(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COMA'
Town of Southold CQG Application No. ")/6Judith T. Terry, Town Clerk /
Town Hall, 53095 Main Road _ -< Residential
P. O. Box 1179 cry e__ '� {� ;' Non-Residential
Southold, New York 11971 OO � •,,
Telephone ,( * Y '"
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: Rif vi r gf p n i e„
OWNER MAILING ADDRESS: ?e ,1 s moi. t2 - E v
C. i. / I OZP /Q e.1. / ' '2
OWNER PROPERTY ADDRESS: S yyx a
OWNER TELEPHONE NUMBER: 596 .743
TAX MAP NO. : Section/e C .r 14 Block Lot
CROSS STREET: 70Cc,�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential , Non-Residential
DATE OF PREVIOUS PUMP-OUT: j .'-/r) � ,� /2 ) t
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.) /'7
Sinature of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE:
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