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JUDITH T.TERRY �►��_� ye. Town Hall, 53095 Main Road
TOWN CLERK ti = P.O. Box 1179
v. t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Oy ��� Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER 1�® J�L 10i� Telephone(516) 765-1800
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FREEDOM OF INFORMATION OFFICER �•.�,,..•�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3403-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PIM, JAMES H.
Mailing Address 1 750 REEVE AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 750 REEVE AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9409
Tax Map No. section 114.00 block 11 lot 30.000
Cross Street NEW SUFFOLK AVENUE
Issue Date: 10/27/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
or
OFFICE OF THE TOWN CLERK 1cl\ FOL4- '`
Town of Southold 1 Q CQ ; Application Nct. 90
Judith T. Terry, Town Clerk
Town .Hall, 53095 Main Road ` -< $10.00 - Residential
P. O. Box 1179 tri • i ;' $25.00 - Non-Residential
Southold, New York 11971Obi ;" ��`
Telephone = .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
61)
Fee $ /• D
DATE (J c„-%, La—
Ir
OWNER NAME: O m�.s 1] . '77
OWNER MAILING ADDRESS: 7 S-0 /Ze Pe-
OWNER PROPERTY ADDRESS: 3-0 fZ&_e
OWNER TELEPHONE NUMBER: 2 '97- q 4 09
TAX MAP NO. : Section / /4 Block // Lot ,3�3
4\
CROSS STREET: /YR44...)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential a/ Non-Residential
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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2
Signature of Applicant
RECEIVED BY:
Town Clerk's Office - -
DATE:
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