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Mead
OFFatit JUDITH T.TERRY ,0 tANTown Hall, 53095 Main Road TOWN CLERK ® P.O..02PBox 1179 . �� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ® /� Fax(516) 765-1823 MARRIAGE OFFICER 15® •-i11 RECORDS MANAGEMENT OFFICER : .( `1►, ' Telephone (516) 765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3447-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner MEAD, RICHARD Mailing Address 1 P. O. BOX 112 Mailing Address 2 City St Zip PECONIC NY 11958-0000 Property Address 1 COUNTY ROUTE 48 Property Address 2 City St Zip PECONIC NY 11958-0000 Owner Telephone No. 516-734-6787 Tax Map No. section 74.00 block 1 lot 42.005 Cross Street PECONIC LANE Issue Date: 3/13/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK �FFo _ Town of Southold ��� COG Application No.3 7 7 7 'Judith T. Terry, Town Clerk -, Town Hall, 53095 Main Road =< $10.00 — Residential e� P. O. Box 1179 cr2 ' ` $25.00 - Non-Residential • Southold, New York 11971 O $ Telephone 0.( * 0"/ (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No: Fee $ 10, 00 DATE .5 - -ez�p OWNER NAME: Rü,iy'ci ]4ex OWNER MAILING ADDRESS: PC) I I � ?Pc_ ICS 11 / S OWNER PROPERTY ADDRESS: CD • _ _ Te_CA'lt� I Il�5 OWNER TELEPHONE NUMBER: 5)(0 3 107'16- 7 TAX MAP NO. : Section 74 Block / Lot `1" z CROSS STREET: PCGOJvIC TYPE ;OF SYSTEM: Septic-Tank- --New Existing Cesspool ✓ New Existing Residential V Non-Residential 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.) 14‘uol ignature of Applicant . , RECEIVED BY: Thr _ Town Clerk's Office ' _. DATE: ©-et 517001 v I ��