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Town Hall, 53095 Main Road
(:) P.O. Box 1179
� i Southold, New York 11971
JUDITH T.TERRYFAX(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. 1447-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CONNOLLY, CHARLES B. & ANN H. .
Mailing Address 1 PINE ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 PINE ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3588
Tax Map No. section 54.00 block 9 lot 4.000
Cross Street HICKORY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/26/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE, OF THE TOWN CLERK
Town of Southold Q C' Application /�/
Judith T. Terry, Town Clerk '• -=,�G pl? No. ( y�
Town Hall, 53095 Main .
Road 8 -€- t=: -� $10.00 - Residential
P. O. Box 11791514;74 $25.00 - Non-Residential
Southold, New York 11971 • O ® ' '''r �$
Telephoneoj �� �.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD'WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 0V (1/(767c0
DATE
OWNER NAME: rL -5 % 4
OWNER MAILING ADDRESS: Ft e_ /Zp AP
OWNER _PROPERTY ADDRESS: - f -i
OWNER TELEPHONE NUMBER: 176'
TAX MAP NO. : Section Block Lot
CROSS STREET: (a,D/Z 7?oA ''-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residen ,1L
DATE OF PREVIOUS PUMP-OUT: 1' �7 v
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.,)
/i
Signature of Applicant
RECEIVED BY: -
Town Clerk's Office
DATE:
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