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JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ' Fax (516) 765-1823
MARRIAGE OFFICER ��' � Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ® el..
FREEDOM OF INFORMATION OFFICER l.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD—WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3164-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MONAGHAN, RICHARD & MAGDALANA
Mailing Address 1 206 CONCORD STREET
Mailing Address 2
City St Zip EAST WILLISTON NY 11596-0000
Property Address 1 100 FAY COURT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-742-0291
Tax Map No. section 123.00 block 5 lot 13.000
Cross Street CAMP MINOLA ROAD
Issue Date: 1/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I
OFFitt E ,OF THE TOWN CLERK cvFFO(.,r�'=
Town of Southold O CQ ' Application No.
Judith T. Terry, Town Clerk K.
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Town Hall, 53095 Main Road a :;� $10.00 - Residential
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P. O. Box 1179 cn , ":A. • r , $25.00 - Non-Residential
Southold, New York 11971 ® �, i'�1`
Telephone _ 1 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE '
OWNER NAME: 9 D 11i1&4 ➢ ^ r �,A��Al,AyfA �' VoB\(A ""'`l'Ar9
OWNER MAILING ADDRESS: &O1a114 NO-e---R.\)
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OWNER PROPERTY ADDRESS: 10 t tail/r\
MAS 1UNy
OWNER TELEPHONE NUMBER: I o `�� 6,~ d(1
TAX MAP NO. : Section Block c Lot
CROSS STREET: Q i uk,_ A QR.
TYPE OF SYSTEM: Septic Tank New Existing
/
Cesspool `� New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: -3;k0L1 90 91-
LOCATION
-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.)
C2-t 4)v V\
Signature of A p icant
•
RECEIVED BY: AQA.,1 c( , e..(9...e/g4e/c)
1 Town CI rk's Office
DATE: 7,
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