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JUDITH T. TERRY z ` : Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER �Q O� ��, Fax (516) 765-1823
=_ 1 �1� �� Telephone (516) 765-1801
jg,OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2029-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEREEDER, JOHN F.
Mailing Address 1 P. O. BOX 1322
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 525 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9755
Tax Map No. section 114.00 block 11 lot 19.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 12/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER •
1)°4°.
® ®�' ��� Fax (516) 765-1823
=; -701 �1D ��� Fax
(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. 2029-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEREEDER, JOHN F.
Mailing Address 1 P. O. BOX 1322
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 525 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
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Owner Telephone No. 516-298-9755 /9t-
Tax Map No. section 114.00 block 11 to .000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 12/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 0c3\\FF�(,r '=
Town of Southold �% j.ft�. CQ Application No..q® a q
Judith T. Terry, Town Clerk ` A' :x,'' ' ; k:,�� /
_a -� :�_��,> < $10.00 - Residential 4/
Town Hall, 53095 Main Road ; in
P. 0. Box 1179 v' t. {�,•,'•' : $25.00 - Non-Residential
Southold, New York 11971 0T ''''1--
' `'�% �$
Telephone of 0,
(516) 765-1801 ..
• •' • TOWN OF SOUTHOLD
SOUTH.OLD WASTEWATER DISPOSAL DISTRICT
,° RECEIVED APPLICATION
DEC 21 .s tir for
Southold Town Clerk , OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $ •,-
DATE '5)..,c,eo 1l19'11-
OWNER
9'11OWNER NAME: -3741-1'', I • die-. '\ Q++r
OWNER MAILING ADDRESS: 1.O • Sx 32.2.
1--1,444-i-fix I4. `t'. 119'5 2-
OWNER
OWNER PROPERTY ADDRESS : 5Z5- IVe UAd« 1qJ v‘L
OWNER TELEPHONE NUMBER: 151G-Z9$' `l'7v'r5 /Z4$-gOOd
TAX MAP NO. : Section /111 Block 0 Lot lo
CROSS STREET: Ay g.4,�� 25
TYPE OF SYSTEM: Septic Tank New Existing 4.
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.)
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S ,41' - re of Applicant
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RECEIVED BY: i lam _A ,?__-9--/
T wn CI rk's Office
DATE: /1, -'-' GSI ` g' D - - -
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