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V'13 Town Hall, 53095 Main Road q12' /� = `' P.O. Box 1179 = ®� titSouthold, New York 11971 JUDITH T.TERRY ��" FAX(516)765-1823 i�zr' TOWN CLERK TELEPHONE(516)765-1801 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. 1124-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner SOULLAS, PETER Mailing Address 1 300 HERRICKS LANE Mailing Address 2 City St Zip RIVERHEAD NY 11901-0000 Property Address 1 1445 CAPTAIN K I DD ROAD Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-722-4268 Tax Map No. section 106.00 block 5 lot 15.000 Cross Street ZENA ROAD Date Of Last Pump Out 0/00/00 Issue Date: 5/24/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) • , - ;T .. ..:.. • ii. OFFICE OF THE TOWN CLERK �SFFOCA- Town of Southold ' ,K,-9''',v, � L'� = Application No.//2. Judith T. Terry, Town Clerk % ,i;-:1:.. y ~ °� ° ,�� .0 1 Residential i/ Town Hall, 53095 Main Road '-; 4 C:' ..r:.F V=•.-9 P. O. Box 1179 - . r <" Yi f�� Non-Residential Southold, New York 11971 O ®_ ::, � Telephone Q( , 0 '9 • (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ /a DATE0-- OWNER NAME: ei-ev2 c /iRS OWNER MAILING ADDRESS: 300 //1�/(72-/6/-c5 L/lr✓t- /1iei'h(919. )/ JJC' //qe/ OWNER PROPERTY ADDRESS: /`V/ .fi ei9Pt i/�) :) i_l)D Rd /4/'77 i c/ ip1/ //9�2 OWNER TELEPHONE NUMBER: ./7-10;140 —/1/C 6g { TAX MAP NO. : Section //0 6 Block 3 Lot f33r - CROSS STREET: Z61 O/ e i� TYPE OF SYSTEM: Septic Tank New Existing Cesspool i/ New Existing 1/ Residential it Non-Residential DATE OF PREVIOUS PUMP-OUT: /06-V67 LOCATION MAP: Must be attached hereto before permit may be issued. 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