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JUDITH T. TERRY $ Aft 'Ai Town Hall, 53095 Main Road
TOWN CLERK �� r, ' P.O. Box 1179
REGISTRAR OF VITAL STATISTICSitv * y° �� Southold, New York 11971
MARRIAGE OFFICERFax
Telephone l(5 6) 7651801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1681-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MITCHELL, LAWRENCE A.
Mailing Address 1 P. O. BOX 135
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4145 BAY SHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11971-0000
Owner Telephone No. 516-765-1909
Tax Map No. section 53.00 block 6 lot 4.000
Cross Street ISLAND VIEW LANE
Date Of Last Pump Out 0/00/88
Issue Date: 5/07/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c\\VFOL4 - `
Town of Southold Application No. /
6 r(
Judith T. Terry, Town Clerk =-A %1
Town Hall, 53095 Main Road
o
.;: : $10.00 - Residential
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P. O. Box 1179 c .'
ry 's� � Asx- $25.00 - Non-Residential
Southold, New York 11971 O ®_
Telephone •
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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 $
DATE ?j_
OWNER NAME: Za,610/R•eviCe of /2)A , •
OWNER MAILING ADDRESS: f, .30X /35-
_ --C70 0-,te) Aty ':
OWNER PROPERTY ADDRESS: - / r � �V °dolke g'a1-C
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l
OWNER TELEPHONE NUMBER: `�7 7 r--- ( ,
TAX MAP NO. : Section Block / Lot
S-C)
CROSS STREET: s(C/ti1 c/ /4e/-1--
TYPE
4QwTYPE OF SYSTEM: Septic Tank 1 New Existing
Cesspool New Existing
Residential �' Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto befo✓✓re 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:
Town Clerk's Office
DATE: