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JUDITH T. TERRY a - .-Y "f, Town Hall, 53095 Main Road
TOWN CLERK = l� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Is; ? 1 } Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1622-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HOGAN, JOHN M.
Mailing Address 1 99 WOODNUT PLACE
Mailing Address 2
City St Zip MINEOLA NY 11501-0000
Property Address 1 15 YOUNGS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-248-7231
Tax Map No. section 114.00 block 10 lot 33.001
Cross Street SHIRLEY ROAD
Date Of Last Pump Out 0/00/00
"Pen fe'4211
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL) -
-Se
-
OFIICE OF THE TOWN CLERK VFFU1A-
Town of Southold �S Application No. /6 -2-
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
.G $10.00 - Residential
P. O. Box 1179 cr3 P fir:, - ' h�i ; $25.00 - Non-Residential
Southold, New York 11971 O ® ��•`
Telephone *e./ Y► 0
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
- . OPERATION PERMIT
SEPTIC TANK. or CESSPOOL •
Operation Permit No.
CO
Fee $ /()
DATE 2-- -2.S( ()
•
'OWNER NAME: TO �} (� M , 140 c)A \J
OWNER MAILING ADDRESS: c c woo UN u T PL
�Ni ern., A 0 V\,0 I
OWNER PROPERTY ADDRESS: 1. ' Q (3 G S
Pr 1 1 A TU C K I N. i L\ 95
OWNER TELEPHONE NUMBER: .'fS' -`7 2-3 I ( M weak ft)
TAX MAP NO. : Section 1 11-4 Block I ( Lot -32_ C33
X33.. 1 )
CROSS STREET: - �` - \e Ropi ci
TYPE OF SYSTEM: Septic Tank _ New Existing
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: No- '*ori cocwteclie,CbeCt za,Out-Y kc190,
LOCATION MAP: Must be attached hereto before, permit may be issued.
(Locate building and system; give north arrow and feet
Qf distance, approximately, to building and closest road.)
Cesflosornl
®q' roCad
oo-NGS AuE `
4 Signature of Appli t
RECEIVED BY: _ _ - _. _
Town Clerk's Office
DATE: