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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK e P.O. Box 1179
REGISTRAR OF VITAL STATISTICSSouthold, New York 11971
MARRIAGE OFFICER � � Fax (516) 765-1823
__ 19. ���! 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. 1801-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MATTITUCK PRESBYTERIAN CHURCH
Mailing Address 1 MANSE
Mailing Address 2 P. O. BOX 1411
City St Zip MATTITUCK NY 11952-0000
Property Address 1 125 REEVE AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4145
Tax Map No. section 114.00 block 9 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'o
OFFICE OF THE TOWN CLERKPFFD
Town of Southold �� �CQ Application No. ,/1 .° 11
et-
Judith T. Terry, Town Clerk � t � i - l/
Town Hall, 53095 Main Road '�,= r4 ' $10.00 - Residential
P. O. Box 1179 crs x x =" z $25.00 - Non-Residential
Southold, New York 11971 ,4411%
O� •
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ID OD
• DATE ��J-17—
OWNER NAME: PI i9 -JTUc(c 1q .S ten a-4A ( c/�''���
OWNER MAILING ADDRESS: (YoX /fY//
/zz/,T(nick ,t1 V /✓ Hca
OWNER PROPERTY ADDRESS: //S
,41/9-171 7-1,1 c...f c /79S-2_
OWNER TELEPHONE NUMBER: 9F-
TAX MAP NO. : Section Block Lot
CROSS STREET: ,"*'
TYPE OF SYSTEM: Septic Tank New Existing
.. _ - " Cesspool ki New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: tlepleit-q 19er 1 qi
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.)
i
Signatudre of ppIica>�
RECEIVED BY:
Town Clerk's Office
DATE:
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