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JUDITH T. TERRY ,�o-® Gym : Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
REGISTRAR OF VITAL STATISTICS v T , Southold, New York 11971
MARRIAGE OFFICER : �� Fax (516) 765-1823
r 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. 1699-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LEIGHTON, ROBERT A.
Mailing Address 1 BOX 1457
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 335 ROCHELLE PLACE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8374
Tax Map No. section 144.00 block 4 lot 10.000
Cross Street SALT LAKE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 6/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE Oita THE •TOWN CLERK • �FFO(,r�'=
Town of Southold TCQG �
Application No. � ��
Judith T. Terry, Town Clerk , � y
Town Hall, 53095 Main Road �'
.- . $10.00 - Residential
P. O. Box 1179 TAM: ;, -r �` $25 .00 - Non-Residential
Southold, New York 11971 �
Telephone 4104-
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(516)
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE \0.(///1
OWNER NAME: /Co66 i (4 L1!C/k(•Ta "
OWNER MAILING ADDRESS: /3 Y /9.`7
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OWNER PROPERTY ADDRESS: 3S- rgoedgeae" 19411
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OWNER TELEPHONE NUMBER: ( t\ Zq.= c.374
TAX MAP NO. : Section 144 Block Lot (, 0'
CROSS STREET: SAC L Lai/g,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing l0
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: tri43/ 1
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.)
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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