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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK � _ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS P� Southold, New York 11971
��� Fax (516) 765-1823
MARRIAGE OFFICER
���! 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. 1673-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BLAIS, MARISA A.
Mailing Address 1 P. O. BOX 181
Mailing Address 2
City St Zip PECON I C NY 11958-0000
Property Address 1 ROBINSON LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-6747
Tax Map No. section 98.00 block 4 lot 36.000
Cross Street INDIAN NECK LANE
Date Of Last Pump Out 0/00/80
•
Issue Date: 4/22/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFhCE OF THE TOWN CLERK ���F�� ''•
Town of Southold Q COG Application No. A73
Judith T. Terry, Town Clerk .40vr 0 '°
Town Hall, 53095 Main Roadw �,,� _ $10.00 - Residential c/
P. O. Box 1179 cn s a' a
VA ,,.�-�.- �, $25.00 - Non-Residential
Southold, New York 11971 4 ' •*
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ //
DATE ,,T'l6'41
OWNER NAME: iQ1 &4is •
OWNER MAILING ADDRESS: PP. 8016 lel
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OWNER PROPERTY ADDRESS : k0.6(4150,4)
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OWNER TELEPHONE NUMBER: 676'73K-674/67
TAX MAP NO. : Section 'L4 Block le Lot 326
CROSS STREET: 34) Hi 444 AIir6t< G
TYPE OF SYSTEM: Septic Tank 0/ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: I 1r10
LOCATION MAP: Must be attached hereto before permit may be issued. ( Jit)
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicgint
RECEIVED BY:
Town Clerk's Office
DATE:
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