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Town Hall, 53095 Main Road
P.O. Box 1179
__® C;,§1 Southold, New York 11971
JUDITH T.TERRY Y ®� " �1� TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 811-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FISHER, HERBERT A. AND WIFE
Mailing Address 1 245 YOUNGS AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 245 YOUNGS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8800
Tax Map No. section 114. 00 block 10 lot 30. 000
Cross Street PINE STREET
Date Of Last Pump Out 8/10/87
Issue Date: 9/02/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COFi7(kC'
Town of Southold , Q 0 Application No. l
Judith T. Terry, Town Clerk .or ) Residential
Town Hall, 53095 Main Road
P. O. Box 1179cra y- i �'
� Non-Residential
Southold, New York 11971
Telephone "461j Y►%0�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. SW
Fee $ f O u
DATE ✓9V •�'! /9PPf
OWNER NAME: le-/dWtrm?r s9. �rJ�
OWNER MAILING ADDRESS: e:2 ",..r Yv,e,e '6-r dp,617.
s°�TTZTL�G/lJ 41/ //9,s-.2
OWNER PROPERTY ADDRESS: cf',42,446-
OWNER TELEPHONE NUMBER: 029 - ,F,00
TAX MAP NO. : Section 11/41 Block Lot ale)
CROSS STREET: AC4'✓.i JI'y
TYPE OF SYSTEM: Septic Tank New • Existing
Cesspool / New Existing 2.
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: OP.7
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 Applicant
RECEIVED BY: , � Ait eL.._ 4AIL .
Town Cler /s Office
DATE:
Sr e 02 8J
Ton Cortii
11/0111
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