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OFFICE OF THE TOWN CLERK c3�FFO(�
Town of Southold ,�. eo . : COI_
Judith T. Terry, Town Clerk ;;
Town Hall,, 53095 Main Road , a , . ,� ;_
P. O. Box 1179 a _ `
Southold, New York 11971 ®���
Telephone - 1 %N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No., 37 Residential xx
Non-Residential
Fee $ 10.00
Septic Cesspool XX
NAME OF OWNER: George W_ T,asce11e
OWNER MAILING ADDRESS: p_p. Box 395
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 480 Private Road 17
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-8177
TAX MAP NO. : Section 123 Block 6 Lot- 19
CROSS STREET: Camp Mineola Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool xx New Existing xx
Residential xx Non-Residential
DATE OF PREVIOUS PUMP-OUT: Nov. 27, 1985eorvoeaaves7oouos...••e4r.
Judith T. Ter
Southold Town Clerk
DATE: September 5, 1986 j
(TOWN SEAL), . .
1, ,'
OFFICE OF THE TOWN CLERK PFFD -
Town of Southold �� _ C�G Application No.37
Judith T. Terry, Town Clerk ` P tor
Residential 1/
Town Hall, 53095 Main Road of
P. O. Box 1179 ,-;°;•LT;•J ' Non-Residential
Southold, New York 11971 O0 �O�'1`�
Telephone _ .� 0 .
(516) 765-1801
TOWN OF SOUTHOLD
RECENTD
SOUTHOLD�� WASTEWATER DISPOSAL DISTRICT
SEP ®5 19
Town Clerk Southold APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 37
Fee $ /O l
DATE gFPT® /1. 1,1986
OWNER NAME: GEORGE W, T.ASC,F,T,LF
OWNER MAILING ADDRESS: BOX 395 ,, MATTITUCK, L.I . 11952
OWNER PROPERTY ADDRESS: 480 PRIVATE RD. 17
MATTITUCK, L.I.
OWNER TELEPHONE NUMBER: 298-8177
TAX MAP NO. : Section /01 3 Block Lot
CROSS STREET: CAMP MINEOT,A RD.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: rl/27/R5
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.)
•A)
• Signature of Applicant
• RECEIVED BY: � � Q� C -C J
Town CI k's Offite
DATE: , e -J. 5 /S
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