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1-q51 ' Town Hall, 53095 Main Road
® _' ,�� P.O. Box 1179
N.157/4
VoiF Southold, New York 11971
JUDITH T.TERRY � �� FAX(516)765-1823
���� TELEPHONE(516)765-1801
TOWN CLERK
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. 1122-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHIP, JOHN H.
Mailing Address 1 BOX 1013
Mailing Address 2 100 GRAND AVENUE
City St Zip MATTITUCK NY 11952-0000
Property Address 1 100 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4353
Tax Map No. section 139.00 block 4 lot 10.000
Cross Street COUNTY RT 48 AND FREEMAN RO
Date Of Last Pump Out 0/00/00
Issue Date: 5/24/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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1O. FICE OF THE TOWN CLERK ���F-FO
"; Town of Southold o� -; CQ Application No. /( ZZL
Judith T. Terry, Town Clerk # r} Y; •
Town Hall, 53095 Main Road n Residential
P. O. Box 1179 c , :• i:Y ► Z' Non-Residential
Southold, New York 11971 O `0'�
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Telephone = .(
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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 $ •
DATE (5.7W T`
OWNER NAME: t--/O%N) V14a
OWNER MAILING ADDRESS: 60 �� loa , ► ,d
3 l4r�e.
OWNER PROPERTY ADDRESS: /00 Csi?irr,I ,-✓,e, 4A-1 k
OWNER TELEPHONE NUMBER: d` 9Y--43 53
TAX MAP NO. : Section E 3 9 Block Lot 0
CROSS STREET: C IQ 4? 4- F" eWta.N Rc(
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing A/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Uj *f w1 L 1 ��
L
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.)
/V . r
Signature of Appl`,=nt
RECEIVED BY: (,(_)/c-Q/Xt.^`
own Clerk's Office
DATE: