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OFFICE OF THE TOWN CLERK • ic���FD
Town of Southold � ;
Judith T. Terry, Town Clerk
Town Hall, 53095-Main Road
P. 0. Box 1179 • r� '
Southold, New York 11971 O +
Telephone
(516) 765-1801 •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 322 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool x
NAME OF OWNER: S.A. Main
OWNER MAILING ADDRESS: Box 106
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: Peconic Bay Bbulevard
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4142
TAX MAP NO. : Section 126 Block 6 Lot 11
• CROSS STREET: Marlene Lane
TYPE OF SYSTEM: Septic Tank New Existing
• Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: , March 24, 1987
Judith T. Terry
• Southold Tdwn Clerk
DATE.: July 14, 1987
•
• (TOWN SEAL)
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OFFICE OF THE TOWN CLERK
is
-
Town of Southoldo
Judith T. Terry, Town Clerk Application Nof�o�o2,
Town Hall, 53095 Main Road Residential /
.1-.:
P. O. Box 1179 cn .
� �,�• ,�{ Non-Residential
Southold, New York 11971 D �� s: •
Telephone : 1 it
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1 ( S �
OWNER NAME: . f\A
OWNER MAILING ADDRESS: (9)4. (®CO
ript oIaJCK
__OWNER PROPERTY ADDRESS: 17E-C, efirg ei.u' D a rod-r OF MA- L; I./b-
OWNER TELEPHONE NUMBER: j. 41,"
TAX MAP NO. : Section ak Block 6, Lot 7/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool v./ New Existing
Residential @/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: -A/L.4/1k 4 7
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.)
cf
/Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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