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'- ' - �� Town Hall, 53095 Main Road
, 0 �s .i` P.O. Box 1179
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''''-4-__/,1 o'� Southold, New York 11971
JUDITH T.TERRY4 ,,�,ii31 - 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. 1269-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BRANDEIS, LYNDAL
Mailing Address 1
Mailing Address 2 P. O. BOX 74
City St Zip ORIENT NY 11957-0000
Property Address 1 21055 ROUTE 25
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2687
Tax Map No. section 17.00 block 14 lot 8.000
Cross Street OLD MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
�, •
OFFIcE OF THE TOWN CLERK SFULtrrr"-
Town of Southold _. COG- Application No. /?6,
Judith T. Terry, Town Clerk tg 'a :\I
Town Hall, 53095 Main Road cn07- `;ln,f Yr< $10.00 - Residential
t i;
P. 0. Box 1179 � �^� $25.00 - Non-Residential
Southold, New York 11971
Telephone Q� `g
rol
111411
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 —
.
0 —. DATE Orifi- 1,6 ( I f Er?
OWNER NAME: L'`fI\LDA-1-- 13R 10E IS Cil2kS3 •
OWNER MAILING ADDRESS: ? 0 7o ({ 6(ic (g157?
OWNER PROPFRTY ADDRESS: Z / 0 SJ /3.? r: (RE __A r
OWNER TELEPHONE NUMBER: 3 2, 3 - 2 G_ g" 7
TAX MAP NO. : Section Block Lot V
CROSS STREET: --
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: l(
t 3-1 <
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.)
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: k Z.
OCT 101
win Clerk Southold