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JUDITH T. TERRY • �• Town Hall, 53095 Main Road
• TOWN CLERK ►Ta P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
td3 Southold, New York 11971
MARRIAGE OFFICER = Fax Fax (516) 765-1823
=___�,y®1 .� 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. 3077-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CAIN, WALTER AND PATRICIA
Mailing Address 1 207 VALLEY VIEW DRIVE
Mailing Address 2
City St Zip WAVERLY NY 14892-0000
Property Address 1 1980 PINE NECK ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 607-565-2481
Tax Map No. section 70.00 block 9 lot 5.000
Cross Street OAKLAWN AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/30/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ���c51FU
Town of Southold , CQ Application No.3
Judith T. Terry, Town Clerk ,
Town Hall, 53095 Main Road -< $10.00 - Residential
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P. O. Box 1179 e �';y $25.00 - Non-Residential
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Southold, New York 11971 O , . ��`�
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Telephone 0t
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK' or CESSPOOL
Operation Permit No.
Fee $ lo
DATE //A0_5
OWNER NAME: ZV/.•CT.C2 72e`CME e1/4/
OWNER MAILING ADDRESS: __ c 7 G'I/-/2-')/ D
UWNER—PROPERTY ADDRESS: /f-re Avz /C,,)
�entr 04.6 / //y/ 1/37/
OWNER TELEPHONE NUMBER: ZC7— ,-.566---- (=2M
TAX MAP NO. : Section 7D Block Lot -
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing ✓
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: %24_) 4� f 7
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.)
Signa'•,u`re of Applicant
RECEIVED', BY.:;J" ; _ - - - -RECIBVir Clerk's Office
DATE: JAIL L' ) its •
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