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Town Hall, 53095 Main Road
' `� P.O. Box 1179
‘Vib‘IFJ' 1 �® Southold, New York 11971
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. 789-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
• New Existing X
Name Of Owner LESSARD, GEORGE G. SR.
Mailing Address 1 3245 GRAND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3245 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4943
Tax Map No. section 107. 00 block 6 lot 14. 000
Cross Street WOODCLIFF DRIVE
Date Of Last Pump Out 0/00/82
Issue Date: 8/16/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK sc31HU(
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Town of Southold �� CQ ' , Application
Judith T. Terry, Town Clerk Z y •
Town Hall, 53095 Main Road Residential
P. O. Box 1179 cn t `J-7 3, Non-Residential
Southold, New York 11971 O '. 1;;,-
Telephone ,( �► 1
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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
OWNER NAME: &E E 4 , ZgS-..
OWNER MAILING ADDRESS: g2fc a
/ 7Ef 4 AJ �S-a—
OWNER PROPERTY ADDRESS: S/p-/moi
OWNER TELEPHONE NUMBER: 9g -' �"
TAX MAP NO. : Section re Block G Lot ` /
CROSS STREET: Jot (o�PPP de_
TYPE OF SYSTEM: Septic .Tank X _New Existing K
Cesspool New J Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /9--/0/2, /9g2-
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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