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OFFICE OF THE TOWN CLERKFU
Town of Southold ��F �fC�G
Judith T. Terry, Town Clerk ,�
Town Hall, 53095 Main Road t. `
P. 0. Box 1179
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Southold, New York 11971 p •�
Telephone _®1 s 0
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 126 Residential x
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Myrtle J. Carr
OWNER MAILING ADDRESS: P.O. Box 109
New Suffolk. New York 11956
OWNER PROPERTY ADDRESS: Fourth Street
New Suffolk, New York
OWNER TELEPHONE NUMBER: 5L6-734-5230
,TAX MAP NO. : Section 117 Block 7 Lot 3
CROSS STREET: King and Orchard
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing x
Residential , g Non-Residential -
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Ter
Southold Town Clerk
DATE: November 6, 1986
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(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.3\\VF�(,� �-
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Town of Southold �® QApplication No. /
Judith T. Terry, Town Clerk
Town Hall 53095 Main Road .0 Residential v
P. O. Box 1179 cra �'"-, t ' Non-Residential
Southold, New York 11971 ;,-fte
Telephone
(516) 765-1801Qkqtq
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TOWN OF SOUTHOLD
u""t) SOUTHOLD WASTEWATER DISPOSAL DISTRICT
aork Southold
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /0 Co
Fee $
DATE 7LY.o U 6 / cl/CC.
OWNER NAME: � � l �i `� ta!rte-
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OWNER MAILING ADDRESS: [3ax —dc, 5 — k at-
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OWNER PROPERTY ADDRESS: Lp
OWNER TELEPHONE NUMBER: 73,/
TAX MAP NO. : Section // Block 7 Lot 3
CROSS STREET: I C I'iv Oge_hAR-2)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing t./-
Residential
i/Residential V 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.)
`/1
`signature Of Applicant
RECEIVED BY:
Town Ierk' e ,
DATE: s- , )FG
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