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JUDITH T. TERRY `- -;.r � Town Hall, 53095 Main Road
TOWN CLERKk° mss'- P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ` rC/� o > �1- Fax (516) 765-1823
✓� ®� � Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1674-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HARRISON, WILLIAM E. & LOIS P.
Mailing Address 1 3535 WESTPHALIA ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3535 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8657
Tax Map No. section 113.00 block 13 lot 20.000
Cross Street DEER PARK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/23/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c.31FU(,' -
Town of Southold OHO _ Cil/ Application No. /c
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road "`r I $10.00 - Residential !�
p. O. Box 1179 c.r3 s F $25.00 - Non-Residential
Southold, New York 11971
Telephone *j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 4/-22- c/
OWNER NAME:
(.21L/.laM C £ Lois P_ Jyi4/nc >i'I soN
OWNER MAILING ADDRESS: 33-3 EsTp1-f,4L/,4 JoAA
nATTIntcl<1 /k `( If 95-2
OWNER PROPERTY ADDRESS: Sae
OWNER TELEPHONE NUMBER: 574- 21 - 74,3-7
TAX MAP NO. : Section /13 Block /3 Lot 20
CROSS STREET: DEER /-4RK / i)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: /2-11- 7.9
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.)
pp
Signature of Applicant
g
RECEIVED BY:
Town Clerk's Office
DATE:
APR 23 11991
,ems -* €c o -1qG - /Si
0e.:4 310-6,(..'-‘" PLEASE SEE REVERSE SIDE BEFORE FILLING OUT THIS FORM, THANK YOU.
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES //k'Q
' GENERAL ENGINEERING SERVICES
.5743318 •�mivc/meav1 N j, r 'V ' 1-'21 S�,vi 144,,-io1v
NAME G )/LL(Afri E. I-/Al6eisoN J (e TELEPHONE NO.- -5-7 ,-21 -SS 7
MAILING ADDRESS 35-3s Cvgcrpy4L,4 R0, . i+-)A-Tr- 1Tticr` ivY , 1 (1 .-2_
ADDRESS (if different from above) -
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