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JUDITH Tr TERRY Town Hall, 53095 Main Road
TOWN c1 ERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER fro 1 Fax (516) 765-1823
.470
�T of 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. 127-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner KREH, JAMES
Mailing Address 1 P.O. BOX 684
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 ROUTE 25
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4929
Tax Map No. section 1 .22 block 6 lot 10
Cross Street FACTORY AVENUE
Date Of Last Pump Out 7/00/89
Issue Date: 4/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FD(,('�'=
Town of Southold �� C� � Application No.
Judith T. Terry, Town Clerk r ' :%
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Town Hall, 53095 Main Road -< $10.00 - Residential
Box 1179 v' ?: ., r $25.00 - Non-Residential
Southold, New York 11971 � , 'fi'4'`
Telephone _0.( ��
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT-
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ Cid
DATE -71/4
OWNER NAME: 1i = jh -'
OWNER MAILING ADDRESS: 60X tc "
n-7/471±-e: ,/r// /I rr2
OWNER PROPERTY ADDRESS: • " C P 17-Q
OWNER TELEPHONE NUMBER: $a:
TAX MAP NO. : Section la, , 6- /0 Block Lot
• CROSS STREET: le-c 74.01 ,4i' _ 4'-,45 •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing )(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7/ g7 •
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.)
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Signature of Applicant
RECEIVED BY: 1
•
'own Clerk's Office
DATE: (L//3 < f7
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