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JUDITH T. TERRY
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
OFFICE OF THE TOWN CLERIC
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
TELEPHONE
(516) 765-1801
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3597-R Residential X Non -Residential
Fee $ 10.00 New Existing X
Name Of Owner REEVE, DAVID
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Mailing Address 1 P. 0. BOX 1157
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Mailing Address 2
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City St Zip MATTITUCK NY 11952-0000
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Property Address 1 1075 NEW SUFFOLK AVENUE
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Property Address 2
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City St Zip MATTITUCK NY 11952-0000
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Owner Telephone No. 516-298-5244
Tax Map No. section 114.00 block 11 lot 24.001
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Cross Street MAIN ROAD
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Issue Date: 3/10/97 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
. to
OFFICE OF THE TOWN CLERK
Town of Southold
Judiflo T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Telephone
( 516) 765-1801
TOWN OF SOUTHOLD
Application N0.�J
$10.00 - Residential -
$25.00 - Non -Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
—APPI'ACATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ��
OWNER NAME:
OWNER MAILING ADDRESS:
DATE -3'" S ` L
L ewe
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO.: Section Block j/ Lot Q2
'CROSS STREET:
TYPE OF- SYSTEM: Septic Tank - New 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.)
c
igna ure of Applicant
.4
RECEIVED -BY: _
REC&M Clerk's Office
DATE:
MAR 1® 199
Southold Town Clark
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