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JUDITH T. TERRY %� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : v T Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
Ci **V$. Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1679-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RYAN, MARY C.
Mailing Address 1 80-12 PENELOPE AVENUE
Mailing Address 2
City St Zip MIDDLE VILLAGE NY 11379-0000
Property Address 1 145 CAPT. KIDD DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 718-894-3515
Tax Map No. section 106.00 block 2 lot 51 .000
Cross Street INLET DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
A O
` L` II I III •
OFFICL' OF tHE TOWN CLERK COFO(,,'I-
Town of Southold Q C� • Application No. 6 "G_
Judith T. Terry, Town Clerk Aw 5 $10.00 - Residential
Town Hall, 53095 Main Road
p. O. Box 11794101,4
W �� $25.00 - Non-Residential
Southold, New York 11971 O +1-e-.1"
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Telephone -Y0 �� �
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l G
DATE Y-j --- A I - Ll 1
OWNER NAME: /Z (2. 2 / /1-/ • •
OWNER MAILING ADDRESS: fo- / re/1/et- y' H V L -
f17/'d4L. l� r ���� �� /Vet -, /2 /{ / ' i
OWNER PROPERTY ADDRESS: / L�-.S 0412i . k , /,/ Df i t"
/1'1At- 6 I iUeie. Nevi Voi21<
OWNER TELEPHONE NUMBER: 7 / S.- Sof - 3s—
td - 2 /
TAX MAP NO. : Section ` 4 2) Block Lot
INLet 0� v -
CROSS STREET: 0/2 P/1 f� �{� t e /Z (� U �
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing Lam'
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: / `7 - 9 o
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.)
d�� / G
Signatye of Applic"nt
RECEIVED BY:
Town Clerk's Office
DATE:
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