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,1r ® Town Hall, 53095 Main Road
JUDITH T. TERRY '4
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF'VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER ��, Fax (516) 765-1823
��® � 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. 1883-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner SCHMITT, PHILIP & SUZANNE
Mailing Address 1 P.O. BOX 271
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1305 ROSEWOOD DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5161
Tax Map No. section 1 .13 block 2 lot 3
Cross Street COX NECK ROAD
Date Of Last Pump Out 5/13/91
Issue Date: 4/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r'JFFICE OF THE TOWN CLERK COFO(,r
Town of Southold Application No. In-,3
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road a~ '24 y $10.00 - Residential
P. 0. Box 1179 cryo , $25.00 - Non-Residential
Southold , New York 11971
Telephone
(516) 765-1801 /
TOWN OF 'SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL, DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 115T 3
Fee $ /0 ,O6
DATE y1/4/9,A
OWNER NAME: P.,01<eip u fr �Nr✓� J' /��l�'J T
OWNER MAILING ADDRESS: 0� �I�JX .27/
/414jr Tkaer1
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OWNER PROPERTY ADDRESS: /30S /a-rePwezd ,l
,-e .-7-0-1 7v ekvyjJ9(s-*
OWNER TELEPH9NE NUMBER: 'c? ?GP 370 /
37°15'O 11709p dF ee€,OV grt,1-74e "
TAX MAP NO. : Section ®0 3 Block Lot
CROSS STREET: CO x A4cJ( i93
TYPE OF SYSTEM: Septic Tank -✓ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 5../3/9/
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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Signature of Applicant
RECEIVED BY: v `- ✓'��=���-�'"`"—b
Town Clerk's Office
DATE: 17II / l�L
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