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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK Z., O r P.O. Box 1179
REGISTRAR OF VITAL STATISTICS If �� Southold, New York 11971
MARRIAGE OFFICER0 Fax�� Fax (516) 765-1823
�,y®1 -tp ��� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3122-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BLANK, MARY LOUISE
Mailing Address 1 2360 PETERS NECK ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 2360 PETERS NECK ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3513
Tax Map No. section 32.00 block / lot 7.000
Cross Street NARROW RIVER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
_4
OFFICE OF THE TOWN CLERK F
Town of Southold AF �`� C' � I
� Q Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cr3 Vis ,? �` $25.00 - Non-Residential
Southold, New York 11971 O O�
Telephone ®j i `N°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for RECEIVED
OPERATION PERMIT tt' 1 7 1993
SEPTIC TANK or CESSPOOL 9 ,kaFavid Yawn Clerk
Operation Permit No.
Fee $ •
DATE
OWNER NAME: ;ieziAY �fy 9�'T S Vzmoic--
OWNER
MAILING ADDRESS: 7--'e1v6 )t7-lei 6x: ,47
Or)omv, Y ) / 967
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: /e0 Y j a6.78
TAX MAP NO. : Section 3." Block I Lot 7
CROSS STREET: !1ahcfecyry £1J Eci7
TYPE OF SYSTEM: 'Septic Tank - - ' New Existing
Cesspool �/- New Existing
Residential " Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
•
CkA
Signature of Applicant
RECEIVED BY: • - -
Town- C -rk's 0 fice '
DATE: G � L `� eg13
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