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JUDITH T. TERRY % ' = �
v, ® Town Hall, 53095 Main Road
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TOWN CLERK P.O. Box 1179
" *IN ; +. Southold New York 11971
REGISTRAR OF VITAL STATISTICS � tri � �'� ,' z , � Fax (516)
MARRIAGE OFFICER �� 765-1823
Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 115-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner PENNY LUMBER
Mailing Address 1 BOX 1440
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 NORTH ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8559
Tax Map No. section 141 .00 block 3 lot 38.001
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
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Issue Date: 1/16/91 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'SFU(,Ur��= iii //6
Town of Southold Q C�G� Application No.
Judith T. Terry, Town Clerk F'tf y
Town Hall, 53095 Main Road :'� ) $10.00 - Residential
p. O. Box 1179 � -<n � �� $25.00 Non-Residential
Southold, New York 11971
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Telephone ..c1/0/ ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE oa/0 3 ) 5'0
-OWNER NAME.: Pe_,-)t-' L-"�`^"�' � •
OWNER MAILING ADDRESS: Ta ox I -{- FD
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OWNER PROPERTY ADDRESS: ,N-0,-1'6t, \,Cx
OWNER TELEPHONE NUMBER: (S/Co) -98 - 8 S59
TAX MAP NO. : Section / if f Block 3 Lot 38"° I
CROSS STREET: So„A, Av-e___ . 8
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool W New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: :AO
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.)
Sign ture ofppA licant
RECEIVED BY:
Town Clerk's Office
DATE:
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