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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICSLen Southold, New York 11971
MARRIAGE OFFICER
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(516) 765-1801
4,1 OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3023-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JOHNNIDIS, FRANCES
Mailing Address 1 90 EAST 25TH STREET
Mailing Address 2
City St Zip HUNTINGTON STATION NY 11746-0000
Property Address 1 120 ZENA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-424-9843
Tax Map No. section 106.00 block 5 lot 24.000
Cross Street RUTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'cOFD(,- -
Town of Southold CQ Application No. 6102, -
Judith T. Terry, Town Clerk
�FP {, ‘) $10.00 - Residential C/
Town Hall, 53095 Main Road � �
$25.00 - Non-Residential
P. O. Box 1179 '�.`
Southold, New York 11971 0��
Telephone ( ��
(516) 765-1801 '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ & 0
DATE I
OWNER NAME: A CLS Inn
OWNER
OWNER MAILING ADDRESS: CAD
OWNER PROPERTY -ADDRESS: eJirvt, Q
AcuttAktkcA,
OWNER TELEPHONE NUMBER: 424 -CK-
TAX MAP NO. : Section Block 5 Lot
CROSS STREET: Qt.cdtki —Q-6C3La
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TYPEIOF,:i•SYSTEM-:-- Septic-Tank------- -New Existing
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.)
- Signatu of Applicant
----- -- -- --- - - --- ---- - --- -- - -- -- - -- - ---
RECEIVED,.;BY-, g.. F - • _`
Town Clerk's Office
DATE: _
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