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WI,- x Town Hall, 53095 Main Road
,� �,+�+ P.O. Box 1179
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I Southold, New York 11971
JUDITH T.TERRY FAX 765-1823
APA.;04•01 TELEPHONE(5 )765 1801
TOWN CLERK
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. 1044-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BIRKMIER, JOHN H.
Mailing Address 1 46970 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 46970 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1575
Tax Map No. section 70.00 block 7 lot 10.000
Cross Street PEANUT ALLEY
Date Of Last Pump Out 0/00/00
Issue Date: 3/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3VFFQ(,(#�'-
Town of Southold �� CQG� , Application No./-0-71-0'
Judith T. Terry, Town Clerk h -ii:-*
A1,1
Hall, 53095 Main Road " -< 7 Residential
P. O. Box 1179 c "' fS4 ,'' i�Z. Non-Residential
Southold, New York 11971 t>"'
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Telephone .( ' '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. lo --(q
,? Fee $ I O • _
DATE :1 a 1
•
OWNER NAME: 1--0\ANN Ot • 1� \1`mi —OWNER MAILING ADDRESS: -(09 -I 0 IA G \\N- (` cL-
,„, 6kd . N - ( \ 9l (
OWNER_.PROPFRTY AnDRESS: - - C (V‘9____-/
OWNER TELEPHONE NUMBER: 1 .b . Lc 1,/ `
J /V
TAX MAP NO. : Section )'-'7---.Q:-.1 Lot
CROSS STREET: --e--7)i6(>74-
7)/6(> di,�,��
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TYPE OF SYSTEM: Septic Tank ' New Existing
Cesspool New Existing
Residential - Non-Residential
G
DATE OF PREVIOUS PUMP-OUT: // i7
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.)
, 1 4[./3/4.4 .
i ' Signature of Applicant i ,,
RECEIVED BY:
3.
VC'
own Clerk's Office
DATE: 3 l q / el
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