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It JUDITH T.TERRY - /° TELEPHONE
TOWN CLERK �� /////��
(516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 649-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner LAWSON, FREDDIE AND MAMIE
Mailing Address 1 BOX 1102
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1070 FACTORY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8173
Tax Map No. section 142. 00 block 1 lot 10. 200
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
/57
Issue Date: 3/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 6cOFO(A,-4.�
Town of Southold Application No
Judith T. Terry, Town Clerk . ��AO
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Town Hall, 53095 Main Road �.: Residential
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P. O. Box 1179 C.fl ; ' ; Non-Residential
Southold, New York 11971 " ® e%l
Telephone '0 r 1Zt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE �� 9
OWNER NAME G L /cr /". /9-077(.:.---- Z/5160 Sort-)
OWNER MAILING ADDRESS: ,ge, //02
/0/97-7—c-��� /0
OWNER PROPERTY ADDRESS: /070 -Gj6 /
J7/ 7/957
OWNER TELEPHONE NUMBER: p12A0 -Q<7_
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic TankExisting
Cesspool New Existing
Residential v Non-Residential
DATE OF PREVIOUS PUMP-OUT: /7
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.)
�atur of Applicant
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•
RECEIVED BY:
Town Clerk's Office
•
DATE:
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