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OFFICE OF THE TOWN CLERK ��c)\\Fair
Town of Southold . lj
Judith T. Terry, Town Clerk � ,��`` J %r '
Town Hail, 53095 Main Road
P. 0. Box 1179 ® � 4R �'•
Southold, New York 11971 Q ` •
Telephone *O./ a '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No. 177 Residential X
Non-Residential •
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: James Ricketts
OWNER MAILING ADDRESS: P.O. Box 794
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 725 Grand Avenue
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4590
TAX MAP NO. : Section 139 Block 3 Lot 30.1
CROSS STREET: Conklin Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown •
Judith T. Terry/
Southold Town Clerk
DATE: December 11 . 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFU `
Town of Southold �� ; - 101 ;, Application No.! J
Judith T. Terry, Town Clerk .` .t ;Os,- *%:\
c�
Town Hall, 53095 Main Road f ^V* Residential
P. O. Box 1179 Non-Residential
Southold, New York 11971
Telephone : .( * 0 I.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /77
Fee $ 119
DATE
•
OWNER NAME: ()AM s / ktTTS
OWNER MAILING ADDRESS: 72- a,V-12- &X 795
.GA .�_ / 2
-
OWNER PROPERTY ADDRESS: ,S' 01 .
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section /3 9 Block 3 Lot
CROSS STREET: - 0-0)112-
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.)
Signature of App scant
RECEIVED BY: 044-1.-ce-c,
Town ffice
DATE: l ECTIVF®
AC111
Town Clerk Southold