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JUDITH T.TERRY e 4:... �'� Town Hall, 53095 Main Road
TOWN CLERK 2 P.O. Box 1179
a� P � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER : 4 ����' Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = .( `�►�®1•0� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3537-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DBM CO.
Mailing Address 1 P. O. BOX 2130
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 215 MOCKINGBIRD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-2223
Tax Map No. section 55.00 block 6 lot 15.060
Cross Street TUTHILL ROAD EXT.
Issue Date: 10/28/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOFoU( --
Town
Town of Southold , Application No. g�
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 $25.00 -$25.00 - Non-Residential
Southold, New York 11971o�r''`�
Telephone ''7q1 )14 I�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 Oo
DATE /6 - 2- 6
OWNER NAME: JJ b M Co
OWNER MAILING ADDRESS: i', O tJ 0 x 13 a
o,e V
OWNER PROPERTY ADDRESS: 2 f J M OGK //\..)64/3 / R j 1-,3 •
SO OTHOI- N 97 1
OWNER TELEPHONE NUMBER: /(a - 4-77- ZZZ3
TAX MAP NO. : Section S Block G Lot AS-, 6 0
CROSS STREET: 7 U 774ILL Rem-b
TYPE OF SYSTEM: Septic Tank o/ New iv' Existing
Cesspool New Existing.
Residential ✓ Non-Residential
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• _�ii,`�
Town erk's Office
DATE: /69/72
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