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JUDITH T. TERRY ,a' c , Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS l� Southold, New York 11971
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MARRIAGE OFFICER �. ® ®� Fax (516) 765-1823
P:4 1 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. 3042-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOCH, WALTER
Mailing Address 1 1160 DONNA DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1160 DONNA DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9305
Tax Map No. section 115.00 block 15 lot 16.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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• OFFICE OF THE TOWN CLERK •SOFO(,( - rr�� (/
Town of Southold &% CQG'; Application No.cJd cL'
Judith T. Terry, Town Clerk % A
Town Hall, 53095 Main Road ;; -'� $10.00 - Residential
P. O. Box 1179 u' '_' $25.00 - Non-Residential
Southold, New York 11971 •'
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Telephone _ 1
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE 3 -p-1 -13
OWNER NAME: koL (' t,ie..
a � OWNER MAILING ADDRESS: I'I(o0 1Da�A. H
C1 J41 P,7"'T I Tv c•1s /UV. W2--
OWNFR PROPERTY ADDREcc:
OWNER TELEPHONE NUMBER: Sly •,2512 -- 930,x''
TAX MAP NO. : Section j/ S Block /5 Lot J,4
CROSS STREET: 1(JfL 5 fFCJLK AaZ
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing ✓
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: /VClv .
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: