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-‘4,17,z4, Town Hall, 53095 Main Road
P.O. Box 1179
'W�Vii'' Southold, New York 11971
JUDITH T.TERRY ,,i1�� 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. 767-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner LUTZ, HENRY K.
Mailing Address 1 1770 REEVE AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11971-0000
Property Address 1 1770 REEVE AVENUE
Property Address 2
City St Zip MATTITUCK NY 11971-0000
Owner Telephone No. 516-298-8566
Tax Map No. section 100. 00 block 3 lot 8.000
Cross Street MILL ROAD
Date Of Last Pump Out 0/00/57
Issue Date: 7/20/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO�
Town of Southold �� . C� = Application No. 7C
Judith T. Terry, Town Clerk �` r
� V?" � 1 Residential >(
Town Hall, 53095 Main Road k
P. O. Box 1179 cni i �`' Non-Residential
Southold, New York 11971 `�l®_r� O. •�`
Telephone - Q( `t�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ J b, Q-e
' DATE Orli'?
OWNER NAME: )9F/14T2y k. A
OWNER MAILING ADDRESS: / ?7O p2/:l" Y7
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 6-`/6 -�q�J �S �i`O ' v -'
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TAX MAP NO. : Section Block Lot
CROSS STREET: /Y2) R )2--d./4_9
TYPE' OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing )<'•
Residential )< Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 1 A-7
LOCATION MAP: Must be attached hereto before permit may be issued. G n' OA C.<
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of -pplican
RECEIVED BY: _
Rown Clerk's Office
DATE: JUL 201988
Ion Cterk Southold
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