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, Town Hall, 53095 Main Road
P.O. Box 1179
-` ® inn ` sif" Southold, New York 11971
JUDITH T.TERRY „ =0'�' FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 980-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BURGER, EUGENE
Mailing Address 1 2515 PINE TREE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2515 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5217
Tax Map No. section 104.00 block 3 lot 4.000
Cross Street STERLING ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFit E OF THE TOWN CLERK 5�FF0(,t " c}
Town of Southold � CQG� Application No. ! &b
Judith T. Terry, Town Clerk ?,' ii
) Residential
r Town Hall, 53095 Main Road � ��
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P. O. Box 1179 tri Mitt ;' Non-Residential
Southold, New York 11971
Telephone o ���'..
(516) 765-1801 1 �
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE CO it
� I�
OWNER NAME: e(ii (1(t-k-1 f)7(4U1
OWNER MAILING ADDRESS: ZSV-5 17'b-± �T
OWNER PROPERTY ADDRESS: !A (MC
OWNER TELEPHONE NUMBER: 117 4-. c D-
TAX MAP NO. : Section ( v 4 Block Lot 2-\--
CROSS STREET: 2r")
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool N New Existing N
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 Clerk's Office
DATE: F •
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