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JUDITH T. TERRY �At Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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%."4,0 ,.!` Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1826-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANDERSON, SUSAN
Mailing Address 1 -475 RAMBLER ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 475 RAMBLER ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4071
Tax Map No. section 88.00 block 5 lot 32.000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 12/24/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF ,THE TOWN CLERK c
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Town of Southold � C� Application
Judith T. Terry,' Town Clerk '
$10.00 - Residential
Town Hall, 53095 Main Road �� -<
P. O. Box 1179 u' Z1 $25.00 - Non-Residential
Southold, New York 11971 O � 0���`
Telephone : 1 � 'o
(516) 765-1801
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
• Fee $
DATE / 2 ZZ
OWNER NAME=-3S jQ G-TzSd
OWNER MAILING ADDRESS: fes
475 Rdrlf,lei° Rd.
Southold,.N Y 11971
OWNER PROPERTY_ADDRESS:
Tahli Rae`
Southold, N.Y. 11971
OWNER TELEPHONE NUMBER: C- y -7 /
TAX MAP NO. : Section % Block ° s-5 Lot 3 Z
CROSS STREET: /14,4 //'J ,A-W/ E—
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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