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Town Hall, 53095 Main Road
�`� P.O. Box 1179
S-,.71761 $�,. ° Southold, New York 11971
JUDITH T.TERRY `� ,,0FAX(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. 1130-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COYLE, BARBARA
Mailing Address 1 P. O. BOX 1118
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 5330 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5130
Tax Map No. section 117.00 block 2 lot 6.000
Cross Street OAK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/01/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.. ...
OFFICE OF THE TOWN CLERK ������•'-
Town of Southold C '1, c3a
�, D • Application No.
Judith T. Terry, .Town Clerk 1,4744-,4:.
53095 Main Road , ,• Residential (O
Town Hall, � � �M� .
P. O. Box 1179 cn �"`A �.
� � . � ��. Non-Residential
Southold, New York 11971 O x :;r ;OZ' -$
Telephone 1590 �k '�
(516) 765-1801,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /,®, rho
DATE i1 / gle9
•
•
OWNER NAME: 6aiaAap e,5f) / g
OWNER MAILING ADDRESS: 12z
a b ÷o_ipluL e_ Li'-21 5"
OWNER PROPERTY ADDRESS: 6-.3 6
11 .74.07.)- S -c c}icz PIcf / Ccr cl
OWNER TELEPHONE NUMBER: (3) Com) 733 /-so 30'
TAX MAP NO. : Section J / Block 7,1 Lot
CROSS STREET: L.-n.9,4) �� ,� „sj s a� 0416M)
TYPE OF SYSTEM: Septic'Tank New- Existing
Cesspool I/ - New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: // /b1 ��
LOCATION MAP: Must be attached hereto before permitmay be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of ppllcant
RECEIVED BY:
Town Clerk's Office
DATE:
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