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Town Hall, 53095 Main Road'
P.O. Box 1179
3/01 Southold, New York 11971
JUDITH T.TERRY -%.. zi%'' FAx(516)765-1823
TOWN CLERK TELEPHONE(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. 1310-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CASE, HELEN
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 BOISSEAU AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-734-6705
Tax Map No. section 55.00 block 5 lot 15.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 11/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i
OFFICE OF THE TOWN CLERK cvFFO(,(
Town of Southold � -` CSG; Application No./3/
Judith T. Terry, Town Clerk y
.1`A:*3 '' t�; �C 1 10.00 - Residential
Town Hall 53095 Main Road $
P. O. Box 1179
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� ,�_ .nh� '�� $25.00 Non-Residential
Southold, New York 11971 p
Telephone ./e/ "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. fat(.l
Fee $
DATE ///45/411-y
OWNER NAME: 1-/ C •
•
OWNER MAILING ADDRESS: Vo,g j kot /u.- y //73s—
OWNER
/7sOWNER PROPERTY ADDRESS: oGss-rxr Afy 1 -Lcr foil
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OWNER TELEPHONE NUMBER: '7312/- ao j0 5
TAX MAP NO. : Section ,�� Block �5- Lot As-
CROSS
sCROSS STREET: ek71- . y�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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