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JUDITH T. TERRY , T
` Town Hall, 53095 Main Road
,; `, � •
TOWN CLERK ?" T •
P.O. Box 1179
REGISTRAR OF VITAL STATISTICSSouthold, New York 11971
MARRIAGE OFFICER 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. 1735-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANDERSON, FRANK & FLORENCE
Mailing Address 1 715 SHIP'S DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 715 SHIP'S DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1573
Tax Map No. section 79.00 block 3 lot 32.000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/13/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r "I
OFFICEOF THE TOWN CLERK •
OFFICE-,OF
Town of Southold •- CQ -- , Application No. V� 736'
Judith T. Terry, Town Clerk �� `,= y
Town Hall, 53095 Main Road 4 ; , .G $10.00 - Residential
P. 0. Box 1179 ` $25.00 - Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
• APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or. CESSPOOL
Operation Permit No.
Fee $ ,/b,oc
DATE cS)/)/�/
OWNER NAME: /5167//,e / :'4CX/C-
OWNER MAILING ADDRESS: 7/✓- 4 "/
cr 4 i) ti . //F7/'
OWNER PROPERTY ADDRESS: -57,c,"7„ --
OWNER
''7 OWNER TELEPHONE NUMBER: 7 S- /373
TAX MAP NO. : Section Block Lot (2-
CROSS STREET: /17 -77-7( 6 y'// /fG4e
TYPE OF SYSTEM: Septic Tank )c New Existing
Cesspool X New Existing XC`
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /7/97 /99C
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:
Town Clerk's Office
DATE: