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JUDITH T.TERRY `�1" TELEPHONE(516)765-1801
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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. 1330-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner REYNOLDS, EDWARD A.
Mailing Address 1 BOX 1074
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 SALT LAKE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4090
Tax Map No. section 144.00 block 5 lot 16.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 12/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE~OF t'HE TOWN CLERK c\\ FD(,���- -.
Town of Southold �� - CQG Application No./ - F >)
Judith T. Terry, Town Clerk \ ''ti' w
s;� �G 7 $10.00 - Residential
Town Hall, 53095 Main Road -
P. O. Box 1179 cn tz �:yYy^ i \ $25.00 - Non-Residential
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Southold, New York 11971 O • '•��`
Telephone 0.( . i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ fo -
DATE / Z `Z- /l'.P7
OWNER NAME: A-. /2e"y°'��' lc/J
OWNER MAILING ADDRESS: / d I. / 07c-/ N/41/r / i
OWNER PROPERTY ADDRESS! fa. /-7Z he-4c A k'7 6 p /41' �rf zc
OWNER TELEPHONE NUMBER: ace- 54°7- 0
TAX MAP NO. : Section / r--/'-/ Block J Lot /
CROSS STREET: ? A/Eao-cJ ����� ��-��� t� / �
TYPE OF SYSTEM: Septic Tank New Existing X.
Cesspool New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7 // 1" J / Z 0 yea I-.i c7 D,
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.)
Si nat e of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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