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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �® ;'�. Fax (516) 765-1823
�_ ��® �! 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. 1889-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MAIN ROAD ASSOCIATES
Mailing Address 1 P. O. BOX 908
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-734-5212
Tax Map No. section 115.00 block 2 lot 4.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK '��FFp�'•- y;:t,►,
Town of Southold COG_ Application No. f 40..
Judith T. Terry, Town Clerk �` �� 7
Town Hall, 53095 Main Road• ~ -� $10.00 - Residential
P. O. Box 1179 trl • $25.00 - Non-Residential
Southold, New York 11971 OCkz°rter' 0���`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. $
Fee $ /d. ✓I°
DATE 442- C.A., /7, / 79V
OWNER NAME: '4 i✓ 474.5 /4.5-,®ci i07 � S
OWNER MAILING ADDRESS: p. D. (J ') 90
Civ-c�o��d't .�/`�• // 35
OWNER PROPERTY ADDRESS: /44/x✓ Q0/9-
- /LI 4"-i tei4 K
OWNER TELEPHONE NUMBER: 6-76 -73c/
--✓ y/ V
_
TAX MAP NO. : Section / / ,5Block 2- — zc Lot /
CROSS STREET: /tel A 24pore,a CY) a -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool. V 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.)
4_6z
Signature of Applicant
RECEIVED BY:
Town Clerk's Office -
DATE: