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�® �®��,' P.O. Box 1179
401 �t ." Southold, New York 11971
JUDITH T.TERRY ., ,I �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. 1546-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANDERSON, RICHARD W. JR.
Mailing Address 1 P. O. BOX 284
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 4869 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-7080
Tax Map No. section 110.00 block 8 lot 14.000
Cross Street OAK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .COFUC' _
Town of Southold Q . �y Application No. i S `/6
Judith T. Terry, Town "Clerks t. .
Town Hall, 53095 Main Road . $10.00 - Residential
P. O. Box 1179 cn MA, �'fs
t '� ` $25.00 - Non-Residential
Southold, New York 11971 O • T3�'�
Telephone oly W°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 1015--- )60
'OWNER NAME: VRA-1*0) Atik,—.1i)S0)0 f •
OWNER MAILING ADDRESS: PC f6a264-
10 bilk) pct L-k- ev / sge,-
OWNER PROPERTY ADDRESS: L(940 _siA RA
OWNER TELEPHONE NUMBER: 6/(4, 7 3 4.— 76 cj O
TAX MAP NO. : Section j/ 6 Block Lot / c,/
CROSS STREET: 6k_ �(V�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1,4) PY+3 f 2,5
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 ApplicaYt
111
RECEIVED BY: (- 0enOWC D
Town Clerk's Office
DATE: e 5 laq
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