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04
JUDITH T. TERRY �'O Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICSt. %�` Southold, New York 11971
MARRIAGE OFFICER Q ®� Fax Fax (516) 765-1823
�� •�� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2039-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COOK, TRUMAN H.
Mailing Address 1 RR 1, 1590 CHAMPLIN PLACE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 1590 CHAMPLIN PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1571
Tax Map No. section 34.00 block 5 lot 9.000
Cross Street ROBINSON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE' OF THE TOWN CLERK \FFU`'�
Town of Southold Q� CQ Application No.
Judith T. Terry, Town Clerk ` 1 R•f•Y
Town Hall, 53095 Main Road - r >a��� �C $10.00 - Residential 1//, pQ
P. 0. Box 1179 5-3334 ;_4 0 ► � $25.00 - Non-Residential
Southold, New York 11971 O ® ' F
Telephone 0? Nti
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /a. - -
OWNER NAME: Arii//,9,/ /-
OWNER MAILING ADDRESS: / / /5,,D e711911111
PLG,'po2T-) A/6`l u1 Yogi` /7717/V
OWNER PROPERTY ADDRESS: 412/, / •gyp �/{/,�,y��/� PeG
&-#466 0nr, /t/5a-) /e-ic //7 e/e/
OWNER TELEPHONE NUMBER: o76- 477 -45-7/
TAX MAP NO. : Section I-173 e3e3 Block � Lot A,4-0
�5-
CROSS STREET: C/fifi cO[av� ,7LA , 4f9//c.Z5Cr2 /CD i-0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
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:(7j�
Town Clerk's Office
RECEIVE®
DATE:-
„WI 7, 19 93
Town- Clerk So ol0
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