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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK v nom+ P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS _ � Southold, New York 11971
� Fax (516) 765-1823
MARRIAGE OFFICER ® ®�
Itv 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. 3112-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHENONE, RAYMOND AND KATHLEEN
Mailing Address 1 2150 WESTPHALIA ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2150 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9431
Tax Map No. section 114.00 block 7 lot 11 .004
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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`OFFICE. OF THE TOWN CLERK ci\FFD(.,U�
Town of Southold �, CQG', Application No. //�
Judith T. Terry, Town Clerk �`& 15: Y kJ.
Town Hall, 53095 Main Road w < } $10.00 - Residential
P. O. Box 1179 -3 JF : ' � $25.00 - Non-Residential
Southold, New York 11971 O O '�`
Telephone 0( y �1 .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /�•1 0,
DATE ,b(6. /02 /Q9i
OWNER NAME: RayfnO J Q d- 1 f t��--tA SGS /Jv1U•O/v/�
OWNER MAILING ADDRESS: p? /50 (.1U/` sT-0 - --j/-- r ` i
m -nor , ,A)4 /
OWNER PROPERTY ADDRESS: /< 7J L, Ji` STP// 1/ --
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OWNER TELEPHONE NUMBER: c 9 9i/3/
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Li) TAX MAP NO. : Section l/L/ Block .7 Lot
`42 °CROSS STREET:
461
`fiYPE OF SYSTEM: Septic Tank a/ New Existing '
Cesspool 4/ New Existing
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Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 9 /C1 c'j 3
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.) —
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Signa `T e of Ap.licant •
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RECEIVED BY - b(j/(1 '
wn Clerk's Office
DATE: .7((
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