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JUDITH T. TERRY 1,11
Town Hall, 53095 Main Road
TOWN CLERK ® rrra P.O. Box 1179
REGISTRAR OF VITAL STATISTICS • Southold, New York 11971
MARRIAGE OFFICER oY �� Fax (516) 765 1823
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®/1$� 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. 1783-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MITCHELL, JACQUELINE K.
Mailing Address 1 P. O. BOX 840
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8650
Tax Map No. section 115.00 block 7 lot 14.000
Cross Street EASTWARD COURT
Date Of Last Pump Out 0/00/00
Issue Date: 10/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c3IFD(,r���
s , `ftwn of Southold ��� CQG' , Application No. /7?3
Judith `T. Terry, Town Clerk % 4110',, ' ' y
Town Hall, 53095 Main Road o � $10.00 - Residential
P. O. Box 1179 u' 5 ��` $25.00 - Non-Residential
Southold, New York 11971 — ,�` --1,4-0•1
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Telephone' -4,01-4-
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ kr—
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DATE 91xA r1
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OWNER NAME: P_ li N� 4sN 1r�`e-- �
OWNER MAILING ADDRESS: l O O'k
OWNER PROPERTY ADDRESS: Ni 0 k?..00...C.t
OWNER TELEPHONE NUMBER: acg --v050
TAX MAP NO. : Section II 5 Block 1 Lot 1
CROSS STREET: . ero lJ-.cvrelr (2A.-e.(AJ- '
TYPE OF SYSTEM: Septic Tank New Existing . /
Cesspool ' New Existing 10
Residential i- Non-Residential
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DATE OF PREVIOUS PUMP-OUT: ���'���'�;���, ��
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.)
. \\..,.. .-.' cuk_,Q,,
ature o('Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
RECEIVED
OCT ®8 10°'
Tnwn Qlerk Southold
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