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Town Hall, 53095 Main Road
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O �v P.O. Box 1179
4 1 ,;" Southold, New York 11971
JUDITH T.TERRY FAX� �1!I/ FAX(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. 1400-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ALVES, MELANIA LIEBLEIN
Mailing Address 1 3200 NORTH ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 2980 NORTH ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0759
Tax Map No. section 35.00 block 3 lot 4.001
Cross Street GULL POND LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/05/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cAWFO,(
Town of Southold %-J-•-•• '=' `+�- Application No. A--/0 b
Judith T. Terry, Town Clerk 1 451 %'1 $10.00 - Residential
Town Hall, 53095 Main Road L .
v3 '`�. fG'us y!''%
P. O. Box 1179 � � • .,� h�i � $25.00 - Non-Residential
Southold, New York 11971 O ® ' 0 ���
Telephone :oj %eft.
1111 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
'OWNER NAME: Me .o..Y 'J \‘. PAde. S
OWNER MAILING ADDRESS: 3 200 list or-• .
OWNER PROPERTY ADDRESS. �+��4 it® - 1`� "f'' A1
OWNER TELEPHONE NUMBER: 5 1 6 O l s ci
TAX MAP NO. : Section 03 ' 0 0 Block° 3 . 00 Lot 004 , 0 0
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential X Non-Residential
DATE OF, PREVIOUS
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:
T n Clerk's Office
DATE: 372-7.
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