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Town Hall, 53095 Main Road
41 P.O. Box 1179
•►I� Southold, New York 11971
JUDITH T.TERRY — ��
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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. 1501-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CASE, RUSSELL B.
Mailing Address 1 P. O. BOX 945
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 NEW SUFFOLK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6184
Tax Map No. section 116.00 block 6 lot 12.000
Cross Street BAY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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UFFIC€ OF THE TOWN CLERK • 'y ".• A50 (
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Town of SoutholdNo.-6
Application - —
Judith T. Terry, Town Clerk 4.47w y
Town Hall, 53095 Main Road .g $10.00 - Residential
P. O. Box 1179 ` '=`
cry `{ $25.00 - Non-Residential
Southold, New York 11971 O%filto " $
Telephone ( *-1t#1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7A7
OWNER NAME:•
OWNER MAILING ADDRESS: / 2/)k ''
. 1 q.5-1-
OWNER PROPERTY ADDRESS: ."
OWNER TELEPHONE NUMBER: 7 - /
TAX MAP NO. : Section 1/6.--6--1;1"' Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I/ 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.)
`Signatu're of Applicant
RECEIVED BY: '")oC ./2(S •
Town Clerk's Office
DATE: