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JUDITH T. TERRY `4 [F Town Hall, 53095 Main Road
TOWN CLERK ; 111 f P.O. Box 1179
REGISTRAR OF VITAL STATISTICS c - Southold, New York 11971
MARRIAGE OFFICER N� !4�' Fax (516) 765 1823
® 1Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1821-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner MITCHELL, PAUL AND ELLEN
Mailing Address 1 21 MONTROSE PLACE
Mailing Address 2
City St Zip MELVILLE NY 11747-0000,
Property Address 1 MUNN LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-611.3-8898
Tax Map No. section 17.00 block 2 lot 8.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 12/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III .
OFFICE OF THE TOWN CLERK �COFait -
Town of Southold C' /
Off, ,:. :w OG Application No. G �oZ�_
Judith T. Terry, Town Clerk . A +;fx w cc %.1
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Town Hall, 53095 Main Road 57-7 "„ �C $10.00 - Residential x
p. 0. Box 1179 _'`� .:, <�` ;� -
«� ��{��� �""�� �: $25 00 Non-Residential
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Southold, New York 11971 O ® , 0���\
Telephone ,ej �� ,,
(516) 765-1801
_ TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1 0 . 0 0
DATE 11-20-9I
14
OWNER NAME: Pa7!l and Ellen Mitchell •
' OWNER MAILING ADDRESS: 21 Montrose Place
__Melville, New York 11747
OWNER PROPERTY ADDRESS: Munn Lane (Private)
Orient, New York
OWNER TELEPHONE NUMBER: 516 643 8898
a
TAX MAP NO. : Section 17 Block 02 Lot 08
CROSS STREET: Main Road, State Road 25
TYPE OF SYSTEM: Septic Tank x New x Existing
Cesspool x New x Existing
Residential x Non-residential
DATE OF PREVIOUS PUMP-OUT: n/a
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
Garrett A. Strang, Architect
RECEIVED BY:
Town Clerk's Office - -
DATE: