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JUDITH T. TERRY AT
Town Hall, 53095 Main Road
TOWN CLERK p v p� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS , �` Southold, New York 11971
��! Fax (516) 765-1823
MARRIAGE OFFICER ® .�
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Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1959-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ST. JOHN, PATRICK & MICHAELEEN
Mailing Address 1 BOX 1158
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 900 DONNA DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5277
Tax Map No. section 115.00 block 15 lot 18.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/19/92 / Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICEy OF THE TOWN CLERK s5�FFOUr;-
Town of Southold �� := C'Q Application
Judith T. Terry, Town Clerk \ ez '►
•
Town Hall, 53095 Main Road $10.00 Residential
p. O. Box 1179 v' .�•_. x z $25.00 - Non-Residential
Southold, New York 11971 O0' �0�,���
Telephone = 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 •"
DATE ?iI6:199
OWNER NAME: t Mvi®C•Lr�eLe°eri
OWNER MAILING ADDRESS: ,1 o}t, I
1`1 {$ a+u.e.lc Pri 1
OWNER PROPERTY ADDRESS: 5jb® Nnition 61a@ 9ie
/NY 11 ,cQ
OWNER TELEPHONE NUMBER: 3"471I
TAX MAP NO. : Section Block 0 /S- Lot
CROSS STREET: /"etAJ Sc).- '-FOi/c Ave
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.)
saNAL
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Signature of A licant
RECEIVED BY: - - - - -
Town Clerk's Office
DATE:
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