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JUDITH T. TERRY z t► Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER � o
Fax (516) 765-1823
�® �� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3104-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BYRNES, VIRGINIA C.
Mailing Address 1 P. O. BOX 103
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 912 GREAT PECONIC BAY BLVD.
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4734
Tax Map No. section 145.00 block 2 lot 9.000
Cross Street LAUREL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 8/24/93 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK s3FD �p
Town of Southold ����
CQ(*a.
Application No.
Judith T. Terry, Town Clerk Aa is �',
Town Hall, 53095 Main Road ~ $10.00 - Residential
P. 0. Box 1179a ' " $25.00 - Non-Residential
Southold, New York 11971 c:"
Telephone
Telephone *14 0�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE AG- 2-3, /F973
•
OWNER NAME: Vji?(./•ur4 G f37gd s
OWNER MAILING ADDRESS: /90, c/2),3
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• OWNER PROPERTY ADDRESS: �'Z G ZZA1.7 ' At/ vb
Ai/ //f'927
OWNER TELEPHONE NUMBER: Crla — Zg3- q-73 17
TAX MAP NO. : Section Block Lot
CROSS STREET: - /p h 'C1 i _ h4-70
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:. AS4--
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.)
Signat re Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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T44-191
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