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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ' U, �� Southold, New York 11971
MARRIAGE OFFICER = ® Fax (516) 765-1823
°/ oa� � 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. 1786-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CABRAL, MANUEL
Mailing Address 1 1800 HARBOR LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1800 HARBOR LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7497
Tax Map No. section 103.00 block 1 lot 25.000
Cross Street MAIN ROAD
Date Of Last Pump Out 9/19/86
Issue Date: 10/09/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE •OF THE TOWN CLERK •c)\\FF0(�`,•-
Town of Southold �� QG' Application No. /7 es'
Judith T. Terry, Town Clerk '¢` y
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 1179f ' i $25.00 - Non-Residential
Southold, New York 11971 �,O y
Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ,!'', -0-1)
DATE /1/Z?'-' 7- /9(8
OWNER NAME: /1„1,61,r,,/
OWNER MAILING ADDRESS:
,;157'7,,/
OWNER PROPERTY ADDRESS: J-•
OWNER TELEPHONE NUMBER: ,�,�.r® .3 79o.
TAX MAP NO. : Section 7b Block Lot �q
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
, Cesspool. New Existing
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.)
AestAtitac_
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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