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Town Hall, 53095 Main Road
10) V ��' P.O. Box 1179
``✓0 �� i Southold, New York 11971
JUDITH T.TERRY „��� ��� FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1243-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHWARTZ, ROSEMARY BYRNES
Mailing Address 1 P. O. BOX 175
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 1150 HORTON AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4471
Tax Map No. section 141 .00 block 2 lot 4.000
Cross Street WESTPHALIA AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c•AF Ur''-
Town of Southold 0\� e'./....'
Application No./02 L3
Judith T. Terry, Town Clerk -t--4--:�
a .,
Town Hall, 53095 Main Road �:�_,'"aha''1 - �,) $10.00 - Residential `�
tea' ''
P. O. Box 1179 cn � ��`"`
� �'� ��_; �� �, $25.00 - Non-Residential
Southold, New York 11971 O '' f��
Telephone _Q(0 �� .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /6/ '61
DATE 9-1/-
OWNER NAME: /l6-S<-h1 /g'a1 3`/,�14-i27 SQ-A (-L4-7-K_z
OWNER MAILING ADDRESS: pa' °-7( / 7 )---
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OWNER PROPERTY ADDRESS: // J b jdO/ Ovv j)2 •
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OWNER TELEPHONE NUMBER: .2-2b' Y177
J TAX MAP NO. : Section /1( Block D .2- Lot D
CROSS STREET: (,<JeS4-phdc.// -o R"U`-�'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t New Existing
Residential 11,7 Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
4s
S gna r of A plicant
RECEIVED BY: etc-- -
Town Clerk' Office
DATE: ''EcENE
SEP 1219
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