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JUDITH T. TERRY 0 ` Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
�� Fax (516) 765-1823
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MARRIAGE OFFICER � O ®�' •------44149.1311111D ." 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. 3082-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FOX, THOMAS
Mailing Address 1 P. O. BOX 1043
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 365 FREEMAN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5062
Tax Map No. section 139.00 block 3 lot 38.000
Cross Street WICKHAM AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/05/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 111\FFO •
Town of Southold c\ �e A lication No. ads--
Judith T. Terry, Town Clerk . 1,1 ,t•=1---...1' ep
. E $10.00 - Residential �
Town Hall, 53095 Main Road At. -
p. O. Box 1179 tr' $25.00 - Non-Residential
u� mss-�'':� •
Southold, New York 11971 ® '. �0�,•�`
Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
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SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ lb- 4Y?)
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DATE
OWNER NAME: 7-2,e,/of
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OWNER MAILING ADDRESS: eD.,Q®,)( lvs/,3
il/d7474,'11u6,< 4/:// i/95
OWNER PROPERTY ADDRESS: 365` G 2,l4j,gr/ Aa-c7
e //9sz
OWNER TELEPHONE NUMBER: 2 ? O(,.2.
TAX MAP NO. : Section /39' Block Lot 3 f
CROSS STREET: , ,a—„te
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0
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.)
164
n"ure of Ap.licant
RECEIVED BY: o°
Town Clerk s Office
DATE: -/�j
.1111
27 2_710 t 8
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