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JUDITH T. TERRY �� J *A Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T Southold, New York 11971
MARRIAGE OFFICER y, �'�` Fax (516) 765-1823
® 37 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. 1692-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BEEBE, NELSON, E.
Mailing Address 1 40 MADISON STREET
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 40 MADISON STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0569
Tax Map No. section 41 .00 block 1 lot 2.000
Cross Street WILMARTH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/22/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKc•3\\CFJ
Town of Southold ��� . CQG Application No. /6 9
Judith T. Terry, Town Clerk F .!,44 %) f
Town Hall, 53095 Main Road '��" - $10.00 - Residential
P. O. Box 1179w; s � t ' �` $25.00 - Non-Residential
Southold, New York 11971 O ® -r Off' ���`
Telephone of r► .�
•
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. t("9
Fee $ l0
DATE 1"/ 7 I ? ,
OWNER NAME: / 2
OWNER MAILING ADDRESS: Lf'
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OWNER PROPERTY ADDRESS : I> /g.e.-eP '
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OWNER TELEPHONE NUMBER: �/ `7 OS'
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TAX MAP NO. : Section `// Block / Lot �---
CROSS STREET: `i' "'~
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /V e G2f
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:
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