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Town Hall, 53095 Main Road
�� Ij' P.O. Box 1179
��®��'' Southold, New York 11971
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JUDITH T.TERRY -*_11i ,..;r��16FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1341-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BURT, NANCY C.
Mailing Address 1 P. O. BOX 115
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 10725 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4034
Tax Map No. section 122.00 block 1 lot 5.003
Cross Street FACTORY AVNEUE
Date Of Last Pump Out 0/00/00
Issue Date: 12/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �VFO
Town of Southold - ,, C'0 = Application No
Judith T. Terry, Town Clerk r Ai 0 key �/
� rz -G � $10.00 - Residential O •�
Town Hall, 53095 Main Road � �^� ��-� .
P. O. Box 1179 to A 1 .�;r; i $25.00 - Non-Residential
Southold, New York 11971 O�y�� i��"�_,0•�$
Telephone _ j
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ft0 . (5`'
DATE i 9; �e.
OWNER NAME: kanVi (.. gut.tr......A • •
•
OWNER MAILING ADDRESS: R o, 'Os
nAGdoirneic, n , , I . 11q5a---)
OWNER PROPERTY ADDRESS: 1W1c ", -
OWNER TELEPHONE NUMBER: -5'I k - X-.1 - 4031
TAX MAP NO. :• Section C7.2-1 Block / Lot I 3
CROSS STREET: P2I, Pk)-%
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �� New Existing
Residential �' Non-Residential
DATE OF PREVIOUS PUMP-OUT: crzQAsi 198'
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.)
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Signature of Applicant
P
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RECEIVED BY: u.-c,,, �
tELIttlV bwn Clerk's Office
DATE: DEC 1 . 19. -,
Town Clerk Southold
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