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JUDITH T. TERRY e ` :' Town Hall, 53095 Main Road
TOWN CLERKd P.O. Box 1179
CO "°LL Southold, New York 11971
REGISTRAR OF VITAL STATISTICS + Fax (516) 765-1823
MARRIAGE OFFICER ® �v
��� VI,.°1 Telephone (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. 1633-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner JAHN, EDGAR A. AND EVELYN
Mailing Address 1 P. O. BOX 466
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 HOLBROOK LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-3856
Tax Map No. section 113.00 block 6 lot 9.000
Cross Street MILL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• vs. •
OFFICE OF -THE TOWN CLERK �S�FFO(.,-�'-
Town of Southold �� CQG•_ Application No./63 3
Y�zt k 41 �t»
Judith T. Terry, Town Clerk . .lam
Town Hall, 53095 Main Road � s , !� $10.00 - Residential
P. O. Box 1179 cs' z $25.00 - Non-Residential
Southold, New York 11971 ® ° g e�`
Telephone O,/ 'i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 654 R
Fee $, ; 210.00
• DATE 3/1/91
OWNER NAME: JAHN, EDGAR A. and EVELYN •
OWNER MAILING ADDRESS: P.O. Box 466
Mattituck, NY 11952
OWNER PROPERTY ADDRESS: S/S Holbrook Lane,
Mattituck, NY 11952
OWNER TELEPHONE NUMBER: 298-3856
TAX MAP NO. : Section 113 Block 6 Lot 9
CROSS STREET: Youngs Right of Way
TYPE OF SYSTEM: Septic Tank x New //7 Existing
Cesspool x New Existing
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: E(z
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.)
V
Signature Applicant
RECEIVED BY:
Town Clerk's Office
DATE: PZEr
MAR ®419