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JUDITH T. TERRY
` , Town Hall, 53095 Main Road
TOWN CLERK -7t s - !` P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS w '.y+ _;e Southold, New York 11971
MARRIAGE OFFICER -6 Fy,- 4%' Fax (516) 765-1823
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(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. 1753-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOOP, GERTRUDE E.
Mailing Address 1 P. O. BOX 1477
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1260 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8089
Tax Map No. section 143.00 block 3 lot 20.000
Cross Street RILEY AVENUE
Date Of Last Pump Out 0/00/83
Issue Date: 9/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'cl\FFD(,(,''
Town of Southold Z ,,_> CQ - Application No. /17,5-3
Judith T. Terry, JOWfl Clerk ' �1 .� 41k '
Town Hall, 53095 ain Road „'` -'� 7 $10.00 - Residential
P. O. Box 1179 trs r, ik : Zr . $25.00 - Non-Residential
Southold, New York 11971 O ®. ��`�
Telephone .0.( lt% '�� '
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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 $
DATE 64421 /9) / 7/ a
OWNER NAME: . 0E7 DE— 4 k'op
fp
OWNER MAILING ADDRESS: ?O Soy ii .7.9
MA-1 -7 f r vCJ< NY /MS- 2
OWNER PROPERTY ADDRESS: ,MJ�'"
OWNER TELEPHONE NUMBER: 5],(e°-a 99- R® R 9
TAX MAP NO. : Section /e4 3 Block 3 Lot c2 6
CROSS STREET: if' it ,
TYPE OF SYSTEM: Septic Tank New Existing
11
.. _ . q Cesspool New Existing
.. Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: ice''"`. ='s' •
1' i�• .
LOCATION MAP: Must be attached hereto before permit may be issued. I
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Signature of Applican '
RECEIVED BY: L/0.1 /�"�
own Clerk's Office
DATE: / /'2 i 9/
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