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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK o P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER ® �} Fax (516) 765-1823
41 ��®, 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. 2008-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BORGELT, HERMAN
Mailing Address 1 345 NORTHFIELD LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 345 NORTHFIELD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2068
Tax Map No. section 71 .00 block 1 lot 23.000
Cross Street DAYTON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/18/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cFO(,(o
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Town of Southold � CQ ' Application No. 4o O'
Judith T. Terry, Town Clerkp.: 3
Town Hall, 53095 Main Road � � -rs. n /� ' $10.00 - Residential
P. O. Box 1179 u� +Y. ' , $25.00 - Non-Residential
Southold, New York 11971
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Telephone : l l► '0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 02 O
Fee $ f®,' do
DATE ,,,/it/ q
OWNER NAME: HEf/7, O ( C Ll
OWNER MAILING ADDRESS: ,"j 1/5 A of I/If i'i tCI L-A l\ L'
S01L AOLC/ A/ HP/
OWNER PROPERTY ADDRESS: Y1/5- f/OR tl17, LC/ LAW-
Soif,t7oLd
OWNER TELEPHONE NUMBER: ,..576 766 20662
TAX MAP NO. : Section ®W Block (9 / Lot Q 23
CROSS STREET: D/ //Q q R0,4ip
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool � New Existing //
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: of P
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 Apt icant
RECEIVED BY: AL/ il-L&A--/.449
/Town Clerk's Office
DATE: ////.0 ";"(___
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•TO THIS SURVEY,IS A VIOLATJON OF ', .-,' . ..
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SECTION 7209 CF THE NEW,YORK STATE
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