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JUDITH T. TERRY t_ Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
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REGISTRAR OF VITAL STATISTICSSouthold, New York 11971
t Fax (516) 765-1823
MARRIAGE OFFICER ® •
`_ �4/® se/ Telephone (516) 765-1801
' OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3037-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MELLENDER, JOSEPH
Mailing Address 1 BOX 750
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 790 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8984
Tax Map No. section 143.00 block 3 lot 14.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 6/04/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK` ,c�VFFO(,r •
Town of Southold �QG'• Application No. BC-) 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00- Residential
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P. O. Box 1179 $25.00 - Non-Residential
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Southold, New York 11971 '�f ��`
Telephone j ` 0 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
ti
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE _C7V9 3
OWNER NAME: 'TSSe- l m le r
OWNER MAILING ADDRESS: 7470 e oc.„, o>.•
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OWNED:- PROPERTY ADDRESS: 7-47o. , *VQ t o 71'0
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OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / Ct3 Block Lot /7
CROSS STREET:
TYPE OF. SYSTEM: ` Septic Tank New Existing
Cesspool New Existing
Residential Non- esidential
DATE OF PREVIOUS PUMP-OUT: 7` /;67
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:
Ar own Clerk's Office
DATE:
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