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Town Hall, 53095 Main Road
1 O d P.O. Box 1179
� ®fes Southold, New York 11971
JUDITH T.TERRYTELEPH1\ ®� (5 6)7 5oNE
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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. 3568-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PITTS, ARTHUR AND JANE
Mailing Address 1 P. O. BOX 637
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 LLOYD'S LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-765-1008
Tax Map No. section 99.00 block 3 lot 4.007
Cross Street SOUND VIEW AVENUE
Issue Date: 12/27/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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`1 OFFICE OF THE TOWN CLERK cwFFULA-°"=
Town of Southold , O�Q 1Q IL. Application No. a� '-'
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Judith T. Terry, Town Clerk ,
do $10.00 - Residential
Town Hall, 53095 Main Road ,.
P. O. Box 1179 u' ,": ;' M ;' $25.00 - Non-Residential
Southold, New York 11971 v *-$
Telephone 1 y1 ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /C"• OO
DATE / z/� 7/76
OWNER NAME: Ar-tliwr a. PMI's a...0 e, ., ` F. �r ad er � K-P,
OWNER MAILING ADDRESS: P 0. e0 - 617
-t 14.4- .g. /1'>' /171-a
OWNER PROPERTY ADDRESS. - — /D,yatJ Z A.K. cs - ---
/'?4-Wl iet.- o /+/Y // f )
OWNER TELEPHONE NUMBER: (Hi 7(f-/ o 0 ? ((NJ ?J �—� I ? V
TAX MAP NO. : Section ''9.. CO Block 3 Lot (7 00 -2
CROSS STREET: 44./C, •
TYPE OF SYSTEM:-- -SepticTank ' X - -New X Existing
Cesspool New Existing
Residential_ 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.)
Signature of Applicant
RECEIVED BY:
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Town` Clerk's Office
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DATE:
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