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Town Hall, 53095 Main Road
kv O �� P.O. Box 1179
� ��� Southold, New York 11971
JUDITH T.TERRYFAX(516765-1823
��/ TELEPHONE(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. 1139-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STOP I NS K I, SOPH I E
Mailing Address 1 BOX 172
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 315 PINE STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4659
Tax Map No. section 141 .00 block 1 lot 33.001
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/87
Issue Date: 6/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C�� FO(K�'-
Town of Southold ® C®G Application No.//7.
Judith T. Terry, Town Clerk ` y
Town Hall, 53095 Main Road ~ " k� $10.00 - Residential
P. O. Box 1179 �' '�#� ��, $25.00 - Non-Residential
Southold, New York 11971 ® ® 'O '•��`
Telephone Q(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 6/, -/� -q
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OWNER NAME: GO in/41e,, 54.o P 7� •
OWNER MAILING ADDRESS: F30 x G f
OWNER PROPERTY ADDRESS:
VV1a4- - i I1 � < // pis
OWNER TELEPHONE NUMBER: 676 --, 9 a - 4/6 S�P
TAX MAP NO. : Section / 4i/ Block / Lot 3 5, /
CROSS STREET: /06OGIC S Al/c2--
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential 1.
DATE OF PREVIOUS PUMP-OUT: / 9 Sr7
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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Signature of 1.plicant
RECEIVED BY:
Town Clerk's Office
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DATE:
JUN ����
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