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JUDITH T. TERRY �� ; � Town Hall, 53095 Main Road
TOWN CLERK y i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS v T Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765 1823
8�' 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. 1660-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STEWART, JOHN .
Mailing Address 1 P. O. BOX 521
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8407
Tax Map No. section 115.00 block 1 lot 8.000
Cross Street MILL LANE
Date Of Last Pump Out 0/00100
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
..: - r-_rte•
Vara od,
OFFICE OF THE TOWN CLERK 'CAWFUIL-
TcSwn of Southold c\ ..-,�._. CSG Application No. / 6 6Q
Judith T. Terry, Town Clerk . Z ;: •,
Town Hall, 53095 11,1ain Road $10.00 - Residential
p. O. Box 1179 U' f=41t $25.00 - Non-Residential
Southold, New York 11971 �O�'���•
Telephone 6j 4 It •
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /( 6 D
Fee $ 1b.
DATE H/)-R'e_ji /g 199/
OWNER NAME: /.-/,j NI, 57-6 e),427"
OWNER MAILING ADDRESS: e0.40 y ,5-07/ /fig ROA_b
rz�cg. IV, y l/9�a
OWNER PROPERTY ADDRESS: M A r ►J T�'(�f �
NI -7-7 TT/c./C nl y / 195 a
OWNER TELEPHONE NUMBER: S7/9 - ,28*-- cFriO
TAX MAP NO. : Section / 15 Block / Lot 8
CROSS STREET: HILL L/ I'1E
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool New Existing t/
Residential L7 Non-Residential
DATE OF PREVIOUS PUMP-OUT: goki K►.Jocv,O (&i,,2 OWt/P ,5-A,P)
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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71+ ✓
Signature of Applicant
RECEIVED BY: i4 , , .., , _J ,
t own --Jr' 's Of ice
DATE: (- 4'YV
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