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JUDITH T. TERRY • , Town Hall, 53095 Main Road
TOWN CLERK v Fri % P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
r✓ �� Fax (516) 765-1823
MARRIAGE OFFICER 004.
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yo1 �� •� Telephone (516) 765-1801
sitOFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3113-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PERRY, THOMAS AND JO ANN
Mailing Address 1 P. O. BOX 143
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 825 PECONIC LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-7645
Tax Map No. section 75.00 block 5 lot 2.000
Cross Street MAIN ROAD
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 'c31FDU(
Town of SoutholdCQ� Application No. �// 3
Judith T. Terry, Town Clerk , . � �`- r ,.0•A ✓l"
Town Hall, 53095 Main Road " ., :,, . $10.00 - Residential
p. O. Box 1179 crs � :Kj � ` ' •` $25.00 - Non-Residential
Southold, New York 11971 *-$
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Telephone
(516) 765-1.801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /`'
OWNER NAME: Thorna_,s o• Ahn Pq- I('/71
OWNER MAILING ADDRESS: P,E ' / (i3
Pecor,tc , NV l/ 5(8'
• OWNER PROPERTY ADDRESS: ( cone. - - -
OWNER TELEPHONE NUMBER:CS/6) 73(I_
TAX MAP NO. : Section 0 /5 Block OS Lot d�
CROSS STREET: (Y)p„urn ROov
TYPE OF SYSTEM: Septic Tank- New Existing
Cesspool New Existing
Residential (/' 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.)
CJ/ 49
Signature of Applicant
RECEIVED BY: / z7 • -
Town er 's Office _
DATE: ‘712/9 -
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