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Town Hall, 53095 Main Road
�+'® ���`� P.O. Box 1179
__° l®1 ��00 Southold, New York 11971
JUDITH T.TERRY -�,__,,,I,,'I• TELEPHONE
TOWN CLERK (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. 754-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BURNS, SOPHIE
Mailing Address 1 RT. 1, BOX 3
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1305 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5188
Tax Map No. section 103 . 00 block 7 lot 18. 000
Cross Street WILLOW STREET
Date Of Last Pump Out 0/00/00
Issue Date: 7/13/99 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKq\FFQ(A.
Town of Southold yA CQ ; Application No. 7L5
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road g YS . Residential k
P. O. Box 1179tr) " ^, ` h�i �� Non-Residential
Southold, New York 11971 O _�F �0 ��
Telephone 1 '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /O 3- 7.-/
Fee $ /O, no
DATE 5, /7 '
OWNER NAME: e ,
OWNER MAILING ADDRESS: / „1:3-6(---/-
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3—f- 3
//P E"--
OWNER
--OWNER PROPERTY ADDRESS: / s-
//PS//
OWNER TELEPHONE NUMBER: 73/74- - S_/IS
TAX MAP NO. : Section Block Lot
CROSS STREET: CO3,� �`�' °-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing )(
Residential /c Non-Residential
DATE OF PREVIOUS PUMP-OUT: //5 g
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.)
•
Sigr�eture of Applicant
RECEIVED : i/ �r (716, Q ('. 0/(47:3''�- -�' "7 own C `rk's Office
DATE: JUL 13 1988
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