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JUDITH T. TERRY h _ Town Hall, 53095 Main Road
TOWN CLERKx- =� '_ P.O. Box 1179
= `"a =, rri Southold, New York 11971
REGISTRAR OF VITAL STATISTICS '.,.r' ', .':`�. _ ��'
MARRIAGE OFFICER V f .` eh Fax (516) 765-1823
`=® ®�i' Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1578-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LOEFFLER, HENRY J.
Mailing Address 1 535 LUPTON POINT
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 535 LUPTON POINT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5811
Tax Map No. section 115.00 block 11 lot 2.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
o
OFFICE OF THE TOINN CLERK c3IFOLA'
Town of Southold OHO C�G•• Application No./5 71
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road �a <, $10.00 - Residential
P. O. Box 1179 u' 4:7:C1 ` $25.00 - Non-Residential
Southold, New York 11971 ff'®k-t �O •'`�
Telephone 1 [
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
7 41P.
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $ r� •
DATE J 7" o0
OWNER NAME: i k.\ t,e r L I '
OWNER MAILING ADDRESS: 3 r �, G� p-ri r�7 „ •
JAY ➢ UcK d .0 1,k a
OWNER PROPERTY ADDRESS : -------- - -
OWNER TELEPHONE NUMBER: eiff
TAX MAP NO. : Section Block Lot
CROSS STREET: Ai k Tee) le - P
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 9 - yo
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.) ,
fie fo
Si%n..tture .f Apf 's'ant
RECEIVED BY:
Town Clerk's Office
DATE:
IC