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JUDITH T. TERRY ;,O Town Hall, 53095 Main Road
TOWN CLERK O T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS t �� Southold, New York 11971
MARRIAGE OFFICER ® 0� Fax (516) 765 1823
_-,y®1 Ilk NgD 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. 2089-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAB I NO, E I LEEN
Mailing Address 1 2110 COX NECK ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2110 COX NECK ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-1009
Tax Map No. section 113.00 block 10 lot 2.000
Cross Street MEDAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 3/30/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c��FFD(,(�� �t
Town of Southold o CQG' Application No.,O ?
Judith T. Terry, Town Clerk . ' AYit ;
Town Hall, 53095 Main Road �,;
rC I $10.00 - Residential
p. O. Box 1179 ET-2 ,-a, Ort:
$25.00 - Non-Residential
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Southold, New York 11971 O �y
Telephone (// $'°T
- (516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4 (j S
Fee $ /6 r
DATE 3/36/6:73
OWNER NAME: C.! 1 --e-e/in a biY1 U
OWNER MAILING ADDRESS: c \ t o Cep ne,v__ ea.
ma*,-6i�Jc ►n ( I �-�-
OWNER PROPERTY ADDRESS: 0
1 ((0)( feCt
OWNER TELEPHONE NUMBER: cPciS' -ion
TAX MAP NO. : Section 1/ 3 Block / o Lot b c
CROSS STREET: /"7E J i- y 14 ✓L N u L-
..
,. TYPE OF SYSTEM:. Septic Tank 1/ _ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: N O -E- tf.47n Lu
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.)
Signa re of Applicant
RECEIVED BY: - •
Town Clerk's Office
DATE:
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