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tri Town Hall, 53095 Main Road
y® I� P.O. Box 1179
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� Southold, New York 11971
JUDITH T.TERRY --",-,-.7,,,,,,,-1 TELEPHONE
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. 680-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner GREEVES, ROBERT
Mailing Address 1 P.O. BOX 301
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD •
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8210
Tax Map No. section 140. 00 block 3 lot 28.000
Cross Street WICKHAM AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ' `�,
Town of Southold \�� 4�a 6
>"4".."' �� �_ Application No. 6
Judith T. Terry, Town Clerk -'~
Town Hall, 53095 Main Road o . < < { Residential •--s
P. O. Box 1179 �' ..z3 h ' % Non-Residential
Southold, New York 11971 O t_S,` '.�''" .�`
Telephone 1 .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /19--
,9 _
DATE g/gF g
OWNER NAME: VOb6Y 9--k-ee, ile�,S
OWNER MAILING ADDRESS: ami To' ti - ,, iv-oc.k
Oi3ox 2O1
OWNER PROPERTY ADDRESS: eli j'd C..�. / '/ /7 icjE /L v //9r2_
OWNER TELEPHONE NUMBER: 2-?6P—?2 /a
TAX MAP NO. : Section l Y® Block U Lot
CROSS STREET: C� a -- C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
P/ l' ilMile ---
Sig/to oT Applicant
RECEIVED BY: qCI)Ayi a c„. ,
Town erk's Office
DATE:
,)4 2 19
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