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JUDITH T. TERRY Town Hall, 53095 Main Road
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TOWN CLERK O T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 6 Southold, New York 11971
MARRIAGE OFFICER ® O . ,. Fax (516) 765-1823
N1D I•� Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
PERMIT OPERA IGIV PERMI 1
SEPTIC TANK or CESSPOOL
Operation Permit No. 3013-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GALLIGAN, THOMAS
Mailing Address 1 1605 MEDAY AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1605 MEDAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11935-0000
Owner Telephone No. 516-298-4561
Tax Map No. section 113.00 block 9 lot 7.000
Cross Street HOWARD AVENUE
Date Of Last Pump Out 3/30/93
Issue Date: 4/29/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3VFFD(,r '- a�3
Town of Southold �� ,- to-- Application No.
Judith T. Terry, Town Clerk ‘, .Pr;""
Town Hall, 53095 Main Road u 'r C.04.' z' i $10.00 - Residential
X.
P. O. Box 1179 ' :-: ' :' $25.00 - Non-Residential
Southold, New York 11971 %O • ®4 �
,�.- F' ' $
Telephone _ ?j N
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
i
1
Operation Permit No.
Fee $ ® `°
DATE 4 — P- I cA
N--____, af;\__ .(___A, GA
OWNER NAME: t � ®� j� S
OWNER MAILING ADDRESS: 1 COLD S VI e i i. ' A- U e
VI, PN`-cZ I TUc,I-< N J :l. \ v:t s Z -
OWNER PROPERTY ADDRESS: 4,n, Vie I`-5 7 g
OWNER TELEPHONE NUMBER: S Ro - zZ ajt)- , so
f TAX MAP NO. : Section Ii Block d Lot I
CROSS STREET: 43, u- /
0,ebAYAV
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: KO,A-c_‘e_ a.te1 1539 5
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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Signaer of Applic
RECEIVED BY:
Town Clerk's Office - - . . - _ .
DATE:
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