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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK 'aZP.O. Box 1179
REGISTRAR OF VITAL STATISTICS V :2' 4Southold, New York 11971
MARRIAGE OFFICER F �'p 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. 1830-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MASON, MATTHEW AND IOLANTHE
Mailing Address 1 33 WILMARTH AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 33 WILMARTH AVENUE
Property Address 2
City St Zip GREENPORT NY 119114-0000
Owner Telephone No. 516-477-2774
Tax Map No. section 41 .00 block 1 lot 17.000
Cross Street BOOTH PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 1/14/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ,COW '=
Town of Southold A CQG Application No. / 6
Judith T. Terry, Town Clerks L )
$10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179u' � �` $25.00 - Non-Residential
Southold, New York 11971 O -®
Telephone 101 .�� 'e•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
,-
DATE /1---
OWNER NAME: / : //// / L4/r,r
/6-,f04/.
OWNER MAILING ADDRESS: .23 /IV/Z/ 4-i T-N ,�/l
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OWNER PROPERTY ADDRESS: `JJ WIZ-/t//0"-- j- "i-
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4/27— ,M7 //%'y,`
OWNER TELEPHONE NUMBER: `5 ��j r y77 v-77 /
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TAX MAP NO. : ection ��1 Block 6/ Lot /7
CROSS STREET: jOO'T
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 maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY: \_J� �� ���„ �
Own ' ' Office
DATE: 077:er
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