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`� �,�: Town Hall, 53095 Main Road
40 P.O. Box 1179
�� �� Southold, New York 11971
JUDITH T.TERRY jr'�`I FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 1003-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SULLIVAN, ARLENE
Mailing Address 1 2100 NAUGLES DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2100 NAUGLES DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4559
Tax Map No. section 99.00 block 5 lot 25.000
Cross Street ROSE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 2/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK OFO(.,(r45.
- '
Town of Southold , �� ,CQG Application No.
Judith T. Terry, Town Clerk �4 _ y
Town Hall, 53095 Main Road Residential
P. O. Box 1179 cn '_ � ; Non-Residential
vim , = r. .
Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /OOH
Fee $ /0:
DATE . 1( 1( 9
OWNER NAME: Qj ULA—1...1® L V A A m L a N
OWNER MAILING ADDRESS: a—` a U NI A} ut.. Gz L .Ms - R,;
M # 1 T tt.c i N \-1 119 5-a_
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: .9 I-- 9
TAX MAP NO. : Section ci,`9 Block ,fid' Lot
CROSS STREET: E
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / , New Existing A/
Residential V _1 Non-Residential
DATE OF PREVIOUS PUMP-OUT: NONE
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: cd_e__
Town Jerk's ffice '
DATE:
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