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JUDITH T. TERRY
Town Hall, 53095 Main Road
TOWN CLERK ® vtiy P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER
Fax (516) 765-1823
=ea � ii! 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. 1960-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOCH, MARGARET AND ANOTHER
Mailing Address 1 445 WOODCLIFF DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 445 WOODCLIFF DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-3805
Tax Map No. section 107.00 block 7 lot 24.000
Cross Street BROWER ROAD
Date Of Last Pump Out 0/00/86
Issue Date: 8/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
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Town of Southold �r.� CQ ';, Application No. /960
Judith T. Terry, Town Clerk x,
Town Hall, 53095 Main Road o -'� $10.00 - Residential
p. O. Box 1179crs
t;T� ► �' $25.00 - Non-Residential
Southold, New York 11971 O � 0���
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE F/2-0/9 Z ,
OWNER NAME: AlifiG,MET L . koalt - 4A/dn./Lae
OWNER MAILING ADDRESS: 5 ®®esei_/G0 3R,
4477-/'7Z1CeJ /l/ /7,5-.1.-
OWNER
7 5- -
OWNER PROPERTY ADDRESS: 319-/7
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OWNER TELEPHONE NUMBER: 299-- 3g'0,5
TAX MAP NO. : Section AD 7 Block 7 Lot ,2 V
CROSS STREET: €',dz. gh* % 1✓tiL doezvdc, b
TYPE OF SYSTEM: Septic Tank _ New Existing
Cesspool New Existing
Residential V- Non-Residential
DATE OF PREVIOUS PUMP-OUT: affe-ez-z-0
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.)
Si•Nature of Applicant
RECEIVED BY: h° C� ___. _ -
Town Clerk's Office
DATE: , , S -
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