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JUDITH T.TERRY ;®� �° Town Hall,53095 Main Road
TOWN CLERK g t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ` 54' Southold,New York 11971
MARRIAGE OFFICER # • �/ Fax(516)765-1823
RECORDS MANAGEMENT OFFICER =�®,1 4 Volo 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. 3330-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KOCH, BOB AND SON
Mailing Address 1 P. O. BOX 1037
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 560 PACIFIC STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8264
Tax Map No. section 141 .00 block 4 lot 22.000
Cross Street SOUND AVENUE
Issue Date: 1/11/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ,C���Mire"
Town of Southold Q L' 3
DG= Application No. 3 3
Judith T. Terry, Town Clerk . �_ �• y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn " ;' $25.00 - Non-Residential
Southold, New York 11971 OL • 0���`
Telephone Ol 4 ' "
(516) 765-1801
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK ,or CESSPOOL
Operation Permit No. 333 d
Fee $ /Q�
DATE //q /c/S --
OWNER NAME: IOL 50N
OWNER MAILING ADDRESS: Po go?(
/11147-- , i< AV Y
OWNER PROPERTY ADDRESS: 3 O' Rife r Pre- S' f
A/Y
„0.
OWNER TELEPHONE NUMBER: ocre FzCc{
TAX MAP NO. : Section /4// Block Lot 22_
CROSS STREET: 5`oua Ave
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential X 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.)
/&
Signature of Applicant
RECEIVED BY• Air
e'
own Cler s Office
DATE: / /7 /5 5
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