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' ` Town Hall, 53095 Main Road
O O '%, P.O. Box 1179
`a i� Southold, New York 11971
JUDITH T.TERRY
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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. 748-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner FLURRY, THOMAS R. JR.
Mailing Address 1 525 DEEP HOLE DRIVE
Mailing Address 2 P.O. BOX 803
City St Zip MATTITUCK NY 11952-0000
Property Address 1 525 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8751
Tax Map No. section 115 . 00 block 13 lot 5. 000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 5/10/84
Issue Date: 7/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Afftl �'=
Town of Southold 0�� ,, „e4,--. Application No. .-1�
Judith T. Terry, Town Clerk .: ^- y
Town Hall, 53095 Main Road a e
Residential
P. O. Box 1179 cn +, r t = i ;' Non-Residential
Southold, New York 11971 O ®* `''•-,y. • $
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Telephone *j y►
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for __
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. Pli
Fee $ it.
DATE (73-- 51
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OWNER NAME: �
OWNER MAILING ADDRESS: P /OP-z- Sok- E(3.3 -
471 i% ( ' i 4) 1116-2--
OWNER PROPERTY ADDRESS: rc;2 ' 6- lc 1)
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OWNER TELEPHONE NUMBER: G576) a�8- g 745 /
j TAX MAP NO. : Section I (,5(---
Block / 3 Lot
CROSS STREET: g 1% r
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TYPE OF SYSTEM: Septic .Tank New Existing
esspool New Existing
Residential , Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4,,r 10 c(
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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 ';!.• • 'cant
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RECEIVED '{.00% :P,- f /
Town erk's 0 /ice
DATE: JUL01. 1988
Town Clark Southold
,._ ci' 13
Applicant shall prepare neatly drawn sketch. See Department of Health
instruction notes for aid in making sketch and completing application form.
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