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B . :T, , r. Town Hall, 53095 Main Road
'` \-. ��' P.O. Box 1179
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__ jay �� �0' Southold, New York 11971
JUDITH T.TERRYir./ FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 1205-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CORWIN, RICHMOND S. JR.
Mailing Address 1 2564 FOREST KNOLL DRIVE
Mailing Address 2
City St Zip ANNAPOLIS MD 21401-0000
Property Address 1 CAMP MINEOLA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 301-266-0976
Tax Map No. section 123.00 block 5 lot 14.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/03/89 Judith T. Terry
Southold, Town Clerk
- (TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�V�FD(,l '-
Town of Southold o�� - 4e Application No./oZDZ
Judith T. Terry, Town Clerk • • a l.i
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179YM Mi ; $25.00 - Non-Residential
Southold, New York 11971 ' 0�•�`
Telephone = 14.1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $ •
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DATE
OWNER NAME: I<‘e-A-«v N� • Co •
OWNER MAILING ADDRESS: D-{6 1/4-1 P2€"CT -'oma- �r&
OWNER PROPERTY ADDRESS: I rlS 9�c C� tM«e-2) PD
e'TkcuCK ( 1G�
OWNER TELEPHONE NUMBER: -201 2(C. OT76
TAX MAP NO. : Section 1 ).? Block � Lot (9
CROSS STREET:
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TYPE OF SYSTEM: Septic Tank New , Existing
Cesspool 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.)
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/172-L1 66
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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