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JUDITH T.TERRY ; Town Hall, 53095 Main Road
TOWN CLERK ; 4,1* xGx P.O. Box 1179
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Southold, New York 11971
REGISTRAR OF VITAL STATISTICS `
MARRIAGE OFFICER Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = � ��,,/0' Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3740-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KING, MARK D.
Mailing Address 1 P. O. BOX 1039
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 360 GRETON COURT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8782
Tax Map No. section 107.00 block 2 lot 3.002
Cross Street
Issue Date: 12/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1--1
OFFICE OF THE TOWN CLERK
Town of Southold �� CO '_ Application No1"774e
Judith T. Terry, Town Clerk .`� y
Town Hall, 53095 Main Road 8 -� $10.00 - Residential
P. O. Box 1179 to $25.00 - Non-Residential
Southold, New York 11971 O �'`,
Telephone . ?i , '
(516) 765-1801 - 1
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ a°
DATE -�-.L ./7 /9 7
OWNER NAME: 6,17_(( [4
OWNER MAILING ADDRESS: "--P'0, DK D S�
W1A-i-Lk
- OWNER PROPERTY ADDRESS: 3G - (- ens U. .
OWNER TELEPHONE NUMBER: . Z9 r-- s-7 k 2-
TAX
TAX MAP NO. : Section /0 7 Block Z Lot g02""
• ; CROSS STREET: -
TYPE, OE_ SYSTEM: 'S-epti"c'°Tank - New Existing /
Cesspool 4 New Existing t/
Residential j/7 Non-Residential
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.)
ignature o Appli•,!nt
RECEIVED BY: •
Town 'Clerk's Office • , - .•
DATE: ' - • - --
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