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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICSir) Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ‘%44t.,, O� •
o1 �1D �• 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. 2040-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MCCARTHY, THOMAS & MARION
Mailing Address 1 57 WILLOW STREET
Mailing Address 2
City St Zip FLORAL PARK NY 11001-0000
Property Address 1 1200 REYDON DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 80.00 block 4 lot 17.001
Cross Street GROVE DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF THE TOWN CLERK •c3\\V ire
Town of Southold � CQ ' Application No Q3 Vo
Judith T. Terry, Town Clerk . `' �� $10.00 - Residential
Town Hall, 53095 Main Road -'�
P. O. Box 1179 tri . ' • $25.00 - Non-Residential
Southold, New York 11971 ,m
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ loo-0-
•
• DATEa9/`v1/) 193
OWNER NAME: //10/ f /1142.10J C-.167)-1/
OWNER MAILING ADDRESS: ZIA)/ Ci Cer-
eAL- 0 di
OWNER PROPERTY ADDRESS: �p.)0r,9 0 �-o /),€-1-L/f
�oLrHL6 / 4)c,) -/O/ iC 4,ti 1'
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 0 gO, 00 Block!) 04190 O Lot 0 . (?0 I
CROSS STREET: g-ieoVC. b21 ilL-
TYPE OF SYSTEM: Septic Tank- ' -New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
1. I t - ''s
40111r
Sign• ure o Applic t
RECEIVED BY;
- Town Clerk's Office
DATE: -
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