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3� , ,R , ,, Town Hall, 53095 Main Road
P.O. Box 1179
r , -0 Southold, New York 11971
JUDITH T.TERRY ���" 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. 643-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner CANTWELL, BUDDITH C.
Mailing Address 1 P. O. BOX 319
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 2595 PECONIC LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2341
Tax Map No. section 74. 00 block 5 lot 4. 100
Cross Street NORTH ROAD AND MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/08/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.SFO(.,,•'• -�j �
Town of Southold �� ., k4 - Application No. 7
Judith T. Terry, Town Clerk .44
Town Hall, 53095 Main Road 444. -'� Residential
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P. O. Box 1179 0i Non-Residential
Southold, New York 11971 O �
Telephone �j �A� e
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE oZ _ �, ��
OWNER NAME: f3Uj9J / c , eifer//&.ELI- ,1 ,40/0
OWNER MAILING ADDRESS: (Eo X319/
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OWNER PROPERTY ADDRESS: ei,.rj'5- f c APC
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OWNER TELEPHONE NUMBER: 7 r -23W (4t 67&)
TAX MAP NO. : Section 74/, Block 5- Lot
CROSS STREET: /, e-7—t,JEEiIO fJasT Rv 7)/A-/ R.l
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ye-5 New Existing ;/ G iy ;
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: dare., l(5r mg.?
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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Signatur- . Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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