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JUDITH T. TERRY ,ham z` t „ ��� Town Hall, 53095 Main Road
TOWN CLERK r; _a;, `ra, E i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS "'",A " x,3': ;i' Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER
�® .4:44 Telephone 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. 1716-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JORDAN, EUGENE K. 8 VIRGINIA L
Mailing Address 1 9330 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 9330 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8557
Tax Map No. section 122.00 block 2 lot 4.000
Cross Street FACTORY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/02/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c0F(J(e�
Town of Southold r>.� CQG Application No.. /7/4,
Judith T. Terry, Town Clerk ' t" 11 $10.00 - Residential
y
Town Hall, 53095 Main Road t x_
p. O. Box 1179 cry ' ` ` $25.00 - Non-Residential
Southold, New York 11971 0 � " '` ', /
Telephone _oI ���
(516) 765-1801
TOWN OF- SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
. for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /7/(o
Fee $,
DATE ®//���7/
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OWNER NAME: �� I . ,)/�/e,,�2// i°/�4 '44/'
OWNER MAILING ADDRESS: SCJ N.,5—C'�.t//
/0 _ 77 "VI< .l/?
OWNER PROPERTY ADDRESS: 9_33C, ,5 4 ./x/4� 7
7/✓/.��/� �C/ // �
OWNER TELEPHONE NUMBER: 2‘99 Li-67
TAX MAP NO. : Section /24‘10e) Block 6v. ..4 7c I Lot dQ �aU
CROSS STREET: ,�C7l)/Z///9T// / ../�
• TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool )(- New Existing V
•
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3/25/
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.)
/ r
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Signa ore of Applicant
RECEIVED BY: .6P I • '
Town Clerk's Office
DATE:
JUL 011991
Town OM
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