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;;, -A. - K Town Hall, 53095 Main Road
P.O. Box 1179
�®���'� Southold, New York 11971
JUDITH T.TERRY ®� �_,����, TELEPHONE
TOWN CLERK ���4,//��/ (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. 771-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner ROSSWORN, MILDRED
Mailing Address 1 2540 MARLENE LANE
Mailing Address 2 •
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2540 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8804
Tax Map No. section 144. 00 block 2 lot 27. 000
Cross Street PECONIC BAY BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 8/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c��FM/
Town of Southold Q �..` CSG= Application No. 7r4
Judith T. Terry, Town Clerk , � ° ; y
Town Hall, 53095 Main Road :< 7 Residential
P. O. Box 1179 �Y P. j '�i�`' Non-Residential
Southold, New York 11971 s_
�i ,_;•0-/Telephone Q(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE �b /ear
OWNER NAME: / ,� i I i°
OWNER MAILING ADDRESS: 25 -o
It qz
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 6-;(6-
TAX
;((p-TAX MAP NO. : Section LI l Block a Lot7
CROSS STREET: Q /3 //
TYPE OF SYSTEM: Septic Tank • New Existing
Cesspool � New Existing J
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: I a-- /p/fir
/f
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 Applicant
RECEIVED BY: 1 rtm
Town Clerk's Office
DATE: !AUG 01. 146
Tent Clerk Soutltattt
I
I ALTERATION OR
~ { r ` / O THISOSURVDEY IS A VIOLATION OF ADDITI
ON
r a n •
SECTION 7209 OF THE NEW YORK STATE
• ! ! EDUCATION LAW.
- - COI IES OF THIS SURVEY MAP NOT$FARING
TIiL LAI D SU;VEYOR'S INKED SEAL OR
'-, • �.6 9. f ,5 0"A•:
A r /4 0 a EMBOSSED SEAL SHALL NOT BE CONSIDERED
4� TO BEA VALID T.UE COPY
_ r • GUAPANTEES INDICATED HEREON SHALL1RUN
•
' rail
"Brice N •V. o /I:/4 %!J ONLY TO THE PERSON FOR WHOM THE SUGVI
� ,
• _ /i, IS FRE,ARID, AND ON His BEHALF TO THE
.. TITLE COMPANY, GOVERNMENTAL AGENCY Al
�, VI ,F LENDING INSTITUTION LISTED HEREON, AND
qq�� \- 1.1,1 TO THE ASSIGNEES OF THE LENDING INTI-
. i 9 0 �\ _ TUTION. GUARANTEES ARE NOT TRANSFERABI
.� -61 ,t c) Z 1 TO ADDITIONAL INSTITUTIONS OR SUB'4OU,4
1. , ! -. ]L ' In CZ •
/ OWNERS.
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