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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICSSouthold, New York 11971
g �� Fax (516) 765-1823
MARRIAGE OFFICER ® ®�
-r4 �� ,��� 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. 3086-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LLEWELLYN, LEONARD & MARJORY
Mailing Address 1 1625 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1625 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4793
Tax Map No. section 115.00 block 14 lot 20.000
Cross Street RICHARD STREET
Date Of Last Pump Out 0/00/86
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .�OMA' -
Town of Southold CQ �; Application No. 30
Judith T. Terry, Town Clerk ��� Pr
Town Hall, 53095 Main Road _ -� $10.00 - Residential
P. O. Box 1179 ��:t ' .t . ;'
$25.00 - Non-Residential •
Southold, New York 11971 O v;4 .��.
Telephone �j �.�� '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
• 1
APPLICATION
- - • . - - -- for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE X9,9
OWNER NAME: 4,-,9-g.2) CS'- .1/1-494.4,24,4/ se, 3r .a. yG'.,L,ze'zrrd-2t%
OWNER MAILING ADDRESS: /496'it, . �4.z.-• pe;
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-OWNER PROPERTY ADDRESS: --E") °,/.7e::::
- -
OWNER TELEPHONE NUMBER: i•t9fj
TAX MAP NO. : Section Fei7 Block/X.S— ,�,20 Lot
- CROSS STREET: R1Gb` �
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TYPE;OF;. SYSTEM: J Septic Tank -New Existing
Cesspool X New Existing X
Residential X- Non-Residential
DATE OF PREVIOUS PUMP-OUT: /9ffeeori_
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.) �^
7;1-
' Signature of0Applicant
RECEIV•ED:.BY _? _ .._-_,__-- --. Y -__ _-
Town Clerk's Office -
DATE' :" _. .
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