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JUDITH Town Hall, 53095 Main Road
T. TERRY �;
TOWN CLERK P.O. BOX 1179
c� • Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � �:�
MARRIAGE OFFICER �_�®/fr ,�� Fax (516) 765-1823
gij sz IV®44!' Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1947-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GAYDOSI K, MARY
Mailing Address 1 2105 EAST MILL ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2105 EAST MILL ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9451
Tax Map No. section 100.00 block 3 lot 13.000
Cross Street REEVE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/21/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •��
-OFFICE OF THE TOWN CLERK cOFOC,r .
Town of Southold �� - C&G'; Application No. ` - 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 8 it
- 7 $10.00 - Residential
P. O. Box 1179 c.' 4: ' $25.00 - Non-Residential
Southold, New York 11971 0 ' �'„0 ��'
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE I 7?)
�%9
OWNER NAME: /1// /C/ /9 /SOS//<
OWNER MAILING ADDRESS: .97/0,,/- L- f�s % /LJ /L 6 ,e0/-2.)
Am--/-77-7-06:1; /I/./
OWNER PROPERTY ADDRESS : S4 41 r=1,5 /9 •f ou A--
OWNER
=OWNER TELEPHONE NUMBER: 06)
TAX MAP NO. : Section /00 Block 3 Lot /3
CROSS STREET: {ZG1
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool V New Existing (/
Residential j/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: fir=' ' ...1 v N L
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.)
/7/2
Signature/7 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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