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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS tfl �� Southold, New York 11971
v' �� Fax (516) 765-1823
MARRIAGE OFFICER O
Alt �1D� s- 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. 3142-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LABODA, GEORGE T.
Mailing Address 1 P. O. BOX 1048
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1815 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9442
Tax Map No. section 144.00 block 3 lot 9.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 11/16/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
LICE OF THE ,TOWN CLERK �FFa
Town of Southold Z , , mea-% Application No. ` t L4 4-
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road �" ,..- ..dc. $10.00 - Residential
P. O. Box 1179 cry ' W2:--,'-:¢'.•
$25.00 - Non-Residential
Southold, New York 11971 O '® 0���`�
Telephone 416j•y* N� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT;:,---, -,-- ,. ..L._ - _
RECEIVED
APPLICATION
for NOV 01 1993
Southold Town Clerk
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE (Id 2,1 / 9'11.3
OWNER NAME: 6er®!/re T. Za-ed � .1.-
OWNER MAILING ADDRESS: /4. ho'Y focer340 Lie 67$469,-002, 4.
/%%a-P/4/.6 `4/K A f iv Lc�/ 14.6.4-&., 0=/ 3 wo,
OWNER PROPERTY ADDRESS: /,p,'c` AjaitAi¢e, L4•®►_
i.00/1/'c4 1/4 //,7i
OWNER TELEPHONE NUMBER: 46 t-qfivy •
TAX MAP NO. : Section / LH/L% L Block —3 Lot — V'
CROSS STREET: Ste: Ah 7--.1 — SL 1 Ace)uall. *' z•:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing V
Residential V Non-Residential
• DATE OF PREVIOUS PUMP-OUT: �/2�®7%5 - /1/2°3'/9.3
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: S-Q.A-1
TownCI k's Office
DATE: 11 - 6 q�
/'l r t ct/�: —fit-