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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK : ® rrri P.O. Box 1179
th Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = V® t Fax (516) 765-1823
MARRIAGE OFFICER I,`' �® , Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER '_7®,� � ��
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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. 3215-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MERCHANT, THOMAS AND EVELYN
Mailing Address 1 P. O. BOX 71
Mailing Address 2 •
City St Zip MATTITUCK NY 11952-0000
Property Address 1 415 VILLAGE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4268
Tax Map No. section 1111.00 block 6 lot 7.000
Cross Street MAIN ROAD
Issue Date: 6/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
�.'... • • I� / III-
,.OrFICE OF THE TOWN CLERK cOF�(,�
Town of Southold % 4 CQ _� Application No. 3 (2
Judith T. Terry, Town Clerk r,,,
Town Hall, 53095 Main Road a �^ f '5+41., -� 7 $10.00 - Residential
P. O. Box 1179 .
aY 4.4 r7 :$2t.00 - Non-Residential
Southold, New York 11971 O ® � '`' *-�`
Telephone 0I , stze°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 1
OWNER NAME: 71011VIS f e v e(y lt, A , 1 " I rc J 1 C( 171-±I
OWNER MAILING ADDRESS: �, ('� , g G )( - - 7 /
NA /`f- ic � \/ 1 I9Sa
OWNER PROPERTY ADDRESS: L (./('
( ((Ct. C-R' Y Lem
lU -E--/-a --ve-k N ( r 9 5
OWNER TELEPHONE NUMBER: ,` ( (p 02 $ — `f -G csr
TAX MAP NO. : Section 1 ) Block 6 Lot 7
CROSS STREET: Ka>c)“4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool N1 New Existing �l
Residential v Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued. •
(Locate building and system; give north arrpw and feet
of distance, approximately, to building and closest road.)
1
Sig ture of Applicant
--RrECEIVE6 BY:
Town Clerk's Office
DATE:
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