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Town Hall, 53095 Main Road
t ; iV ;�� P.O. Box 1179
�� Southold, New York 11971
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JUDITH T.TERRY TELEPHONE O "�
(516) 765-1801
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. 685-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner SIMONE, MICHAEL J.
Mailing Address 1 BOX 240
Mailing Address 2 ILLINOIS AVENUE
City St Zip MATTITUCK NY 11952-0000
Property Address 1 ILLINOIS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5813
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Tax Map No. section 113 . 00 block 11 lot .
Cross Street WESTPHALIA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK o.COFIV(
Town of Southold CQ Application No. E
Judith T. Terry, Town Clerk s � Tx. �; ,
Town Hall, 53095 Main Road c "' J'z Residential
P. O. Box 1179 °s ��.- �.�;�, �; Non-Residential
Southold, New York 11971
Telephone 01 ‘it\� ��•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 6e-__.5
Fee $ O., OD
DATE125r-W
OWNER NAME: /(j,..,(
OWNER MAILING ADDRESS: Plcc 9_40 f(;,)„-'r5
OWNER PROPERTY ADDRESS : 6--i
OWNER TELEPHONE NUMBER: ,,'l, -,T ( 3
1 / / 3 / / / gym /
TAX MAP NO. : Sections- Block Lot , + -,rte A104-eff
CROSS STREET: (3_54.1rf,,,,.t 0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Z,,
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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Signure of Applicant
RECEIVED BY: !V / 41W44___ •
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DATE: 4//°
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