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OFFICE OF THE TOWN CLERK • .c519:[xC," - -
Town of Southold � �
Judith T. Terry, Town Clerk 0
1 �` Y.4.• 17 '
Town Hall, 53095 Main Road Z � �P. O. Box 1179Southold, New York 11971 `QL 4; � •Telephone �((516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 439 Residential x
- Non-Residential
- Fee $ 10.00
Septic Cesspool x
- NAME OF OWNER: Elinor Dykstra
OWNER MAILING ADDRESS: 38 Driscoll Avenue
Rockville. Centre, New York 11570
OWNER PROPERTY ADDRESS: 495 Horton Avenue
• Mattituck, New York 11952
OWNER TELEPHONE NUMBER: 516-764-0467
TAX MAP NO. : Section 141 Block 1 Lot 26
CROSS STREET: Corner of Pine and Horton Streets
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Jud!th T. _ erry
Southold Town Clerk
DATE: September 28, 1987
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK �FFOur G
Town of Southold C A lication No. d/
Judith T. Terry, Town Clerk ' Di►
Town Hall, 53095 Main Road c Residential
idential
P. O. Box 1179 tr' rY' : Non-Residential
Southold, New York 11971 O�� �
Telephone .�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
TO r
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE -e2f -f" 7
OWNER NAME: i Z/ �/® ,� J)y fi v seg
OWNER MAILING ADDRESS: 3 c��s dLJ,� 4i'i
ee/64,e , • ;J //44,70
OWNER PROPERTY ADDRESS: % f-' / ' ,cj; r.J
OWNER TELEPHONE NUMBER: •3-/G- 7 --o ct67
TAX MAP NO. : Section / 4/ Block Lot 21
CROSS STREET: 6D72sa/ /3/',til . °I-- A4 r 7) S7 c.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
- DATE OF PREVIOUS PUMP-OUT: [,(4,4,,,�„,`�
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.)
-VeZW2/ SSignature e ppicant
RECEIVED BY: � ��
ft _Sown CI k's Off ce
DATE: SEP 281987
Town Cterk Southold -
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