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JUDITH T. TERRY �� �� rj Town Hall, 53095 Main Road
TOWN CLERK V=3
`" P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : Southold, New York 11971
MARRIAGE OFFICER ttTe 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. 122-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner GRAY, JAMES L. & PETER S.
Mailing Address 1 866 SOUTH SECOND STREET
Mailing Address 2
City St Zip RONKONKOMA NY 11779-0000
Property Address 1 12130/40/50 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-588-9730
Tax Map No. section 114.00 block 12 lot 2.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/01/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
„
OF-i'ICE OF THE TOWN CLERK 'c3\ FO/L--
:j Town of Southold --.. CQ ' , Application No. /o2.
Judith T. Terry, Town Clerk ‘ ti' q
Town Hall, 53095 Main Road ~~'°` '' $10.00 - Residential
P. O. Box 1179 - `
.� , ,�� �. �� $25.00 - Non-Residential
Z ' :r
Southold, New York 11971 O ® ' �`
Telephone 4__01
'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $ 25 .00
Ck. 11 ' 0191 pd . DATE
September 23 . 1991
OWNER NAME: James L . & Peter S . Gray
OWNER MAILING ADDRESS: 866 SO. Second St .
Ronkonkoma , N.Y. 11779
OWNER PROPERTY ADDRESS: 12130/40/50 Main Road , Mattituck, N. Y.
Mattituck, N .Y. 11952
OWNER TELEPHONE NUMBER: (516) 588 9730,
TAX MAP NO. : Section 114 Block 12 Lot 2
CROSS STREET: New Suffolk Ave
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Yes New Existing Yes
Residential Non-Residential Yes
i` DATE OF PREVIOUS PUMP-OUT: 8/3/91 No further pumping needed
at this time .
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.)
Signature of Applic t
RECEIVED BY:
RECEIVED-1 Clerk's Office
DATE: rim- p? 1001
Town Clerk Southold
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