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X1r�' Town Hall, 53095 Main Road
�Ji P.O. Box 1179
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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. 3569-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CONSTANT, DOUGLAS AND KARIN
Mailing Address 1 P. O. BOX 225
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 555 VILLAGE LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2646
Tax Map No. section 25.00 block 2 lot 5.001
Cross Street MAIN ROAD
Issue Date: 12/31/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S�FFO(,� _ s
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Town of Southold - � �, CQApplication No. �
Judith T. Terry, Town Clerk
� $10.00 - Residential
Town Hall, 53095. Main Road c ` �; ''�
cn #- ,
P. O. Box 1179 � � ,,� �. $25.00 - Non-Residential
Southold, New York 11971 O z®
Telephone �l`J �►� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION" PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 0._11q(�
OWNER NAME: .1 J(-)LA . 'QS q -144.6Y\ Y�S�-fit`t\-\-
OWNER MAILING ADDRESS: pc.) p)4. 5 -
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,OWNER PROPERTY ADDRESS: "--6-5"-- \ \\c DA.e . awe_ -
-O c\-e N 061
OWNER TELEPHONE NUMBER: T1(,9 - ?x,2.3
TAX MAP NO. : Section 02 Block �,. Lot 6—,
CROSS STREET: \ACx�� C a ( 12,4-
TYPE
12,4--TYPE OF SYSTEM: Septic.Tank • - New " Existing
Cesspool New - Existing
• Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: qg
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
T--
RECEIVED
RECEIVED BY: /,� -
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own Clerk's Office
DATE: ' / �34 ( 06
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