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`� t„� Y �;'i Town Hall, 53095 Main Road
'° ®� t' P.O. Box 1179
EZnSouthold, New York 11971
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JUDITH T.TERRY '.0i
—_ �� 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. 1489-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BELANGER, LINDA
Mailing Address 1 P. O. BOX 34
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 717 FRONT STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0764
Tax Map No. section 48.00 block 1 lot 8.000
Cross Street EIGHTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 6/26/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold 0 "- Application No. /q80
Judith T. Terry, Town Clerk ` .
Town Hall, 53095 Main Road $10.00 - Residential c/
P. O. Box 1179 u3 Y .'" '��'�:�•� •�`"'''* '� ` $25.00 - Non-Residential
Southold, New York 11971 .7413;-401'.:4: -
$_.:k"..71.
Telephone _ j
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $ /400:00
DATE 2 3, (9 9 0
'OWNER NAME: /4.j/tip A. e (LAA)•
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OWNER MAILING ADDRESS: PD Bo X 5 cf
G cy d J -f-1 jv, d /(9 lac
OWNER PROPERTY ADDRESS: 7( 7 FP
R )2.-r /V,r
OWNER TELEPHONE NUMBER: 4(7 7 —d 2 6
TAX MAP NO. : Section Block / Lot 7
CROSS STREET: GlG 1---7y-f S I
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ?jto,(-7 62ci' ro
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 Applica
RECEIVED BY:
Town Clerk's Office
Com' i
DATE:
JUN t 199
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