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JUDITH T. TERRY aZ: Town Hall, 53095 Main Road
TOWN CLERK z. O rP.O. Box 1179
REGISTRAR OF VITAL STATISTICS .� �` Southold, New York 11971
MARRIAGE OFFICER ”yQ O�' , Fax (516) 765 1823
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*1D Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2073-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIMONS, STEPHEN M.
Mailing Address 1 P. O. BOX 1003 -
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2850 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4011 -
Tax Map No. section 107.00 block 2 lot 7.000
Cross Street KNOLLWOOD LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/09/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FQU �v
Town of Southold Q CQ ' Application No. 73
Judith T. Terry, Town TerryAL. xw
Town Hall, 53095 Main Road { 7 $10.00 - Residential
P. O. Box 1179 tri ' j 6 $25.00 - Non-Residential
Southold, New York 11971 $
"4.04 ,"••••
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ izep
// ATE ,/ PA) .
OWNER NAME: S7 `Ped/d/ F P/ 4-7"5
OWNER MAILING ADDRESS: PO- i2o C.)
04_ 1/ '
OWNER PROPERTY ADDRESS:- -
>'07/1-
DDRESS:- ,'07/1-.x'~' y-/ .Y hr ./Cj
OWNER TELEPHONE NUMBER: t-16 -)G/
TAX MAP NO. : Section 73 g-e Block /6) Lot a"'
CROSS STREET: /r1A. c �C
TYPE OF -SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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: e-oLe- __
Town CI rk's Office
DATE: 03 RIMED
MAR 9 1993
Town ank smog
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