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JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK "
REGISTRAR OF VITAL STATISTICS ;l j7 qq' Southold, New York 11971
MARRIAGE OFFICER =� � -'�;• ',�+ '1 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. 1608-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FORRESTAL, RORY AND JENNIE
Mailing Address 1 1065 SALTAIRE WAY
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1065 SALTAIRE WAY
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-2110
Tax Map No. section 100.00 block 1 lot 23.000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 0/00/00 -
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �OFO
Town of,. Southold �� -r,_ �C� Application No. )6 6
f .
Judith T`: Terry, Town Clerk � G
Town Hall, 53095 Main Road -� `x„ :C I $10.00 - Residential
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P. O. Box 1179 E' Z- �',.���_ /moi ; $25.00 - Non-Residential
Southold, New York 11971Telephone _Q( Ofvo/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE I(--0-Z-90
OWNER NAME: jU )• ,fit.
OWNER MAILING ADDRESS: 1065-- w
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: vI a acZ a..l (D
TAX MAP NO. : Section /Qv Block / Lot o7_
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
• Cesspool I//- New Existing ,7f
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: uti�!'
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.)
s-re of Applicant'
RECEIVED BY:
-Town Clerk's Office
DATE:
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SURVEYED FOR:-, :::),ney , ,k-A./A..//E L. / 30QQS7-q,4,
LOCATED AT A-7.4J-T-,7--4/c• , TOWN OF .,_ oC/T,1-low • , SUFFOLK COUNTY N.Y.
LOT 2S •
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MAP OF s4c.T4/eE Es747-Es OFFSETS FROM STRUCTURES , CO. CLK. NO.-ia82 FILED..de. .,3,/_9c, ,
SCALE 1" = ..6o• _ TO RELATIVE BOUNDRY LINES, /�1/id
SUFFOLK CO. TAX MAP DATA:- ON SURVEY, ARE FOR A 0 Li fD vi '�-o
DIST. /� , SEC. /�p,po SPECIFIC USE ONLY, AND �`"' r
SHOULD NOT BE USED FOR Vii
BLK. D/.Qe? LOT 02.5.000 CONSTRUCTION OF FENCES (.\)
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I4v. SURVEYED /14411
199 BY
WILLIAM R. SIMMONS JR.
� i- P/O BOX 377
�;, _ ��"' . - JAMESPORT, L. I., N. Y. 11947
.Z/Z.71.1,-,2-7/// 7-3.i',.;� curn ✓ i FILE NO. /2/B3 PAGE 23 GRID Jam_ 7
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