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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK P.O.Fri
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Cri �` Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
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�1D ,,• 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. 3126-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KLEIN, KATHERINE
Mailing Address 1 485 EAST LEGION AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 485 EAST LEGION AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8054
Tax Map No. section 122.00 block 3 lot 28.000
Cross Street BAY BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK•
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Town of Southold �� �CG A lication No.3102 k
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Judith T. Terry, Town Clerk $10.00 - Residential ^�
Town Hall, 53095 Main Road "
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P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 O
Telephone "4474-1.a 1/�`
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 0,0/93
OWNER NAME: /2G iMeS174✓ a%r-/
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OWNER MAILING ADDRESS: 4,4-- E ,c(% //'9 3,—
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OWNER PROPERTY ADDRESS: S cy"— /4-5-
OWNER
4sOWNER TELEPHONE NUMBER: o2 9g— 7-03 -
TAX MAP NO. : Section r a.(R t 0,0 Block 6 " oo Lot d
CROSS STREET: —6Au')
TYPE OF SYSTEM: -Septic-Tank -- "New Existing
Cesspool New Existing 1/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: !V 144 faG
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.)
Signature of Applicant
RECEIVED BY: --
Town Clerk's Office
DATE:
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