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� .` Town Hall, 53095 Main Road
® ®� : - P.O. Box 1179
;,`�� Southold, New York 11971
JUDITH T.TERRY
%��zz� � �' FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1466-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOORE, JOHN L. AND PHYLLIS R.
Mailing Address 1 P. O. BOX 1444
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 12700 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-765-5239
Tax Map No. section 114.00 block 11 lot 16.000
Cross Street LOVE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/18/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 1•
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Town of Southold . -��G•� Application No./V“
Judith T. Terry, Town Clerk • � r,fO
Town Hall, 53095 Main Road �'� -� $10.00 - Residential ,7
P. O. Box 1179 cr'
,:. _ _ $25.00 - Non-Residential
Southold, New York 11971 O ''4Z, = `.. O .J
Telephone .QST. `A\
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
‘0DATE /Ye
OWNER NAME: t/ O/ch / , /'70e2f'e Gbh AC- /F e Te7Die .
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OWNER MAILING ADDRESS: /270z /21d1i1 gel e0,
e21774—ZfL, /V/ /J 7 f 2—
OWNER
OWNER PROPERTY ADDRESS : 576,MX
f$ -TAOWNER TELEPHONE NUMBER: 117Z - ,21,82 -
TAX
X MAP NO. : Section 1/9 Block // Lot /‘
CROSS STREET: 'A Love La 124
TYPE OF SYSTEM: Septic Tank _New Existing
Cesspool New Existing
Residential Non-Residential
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DATE OF PREVIOUS PUMP-OUT: fj'2/C'h ac�dP ,7S ` / heO&
/6 .4 ni,Irr,rvct' P/v17 /,rvC' 13/L. p fv04 00 .r IYY‘15s i O/l a 1 4'
LOCATION MAP: Must be attached hereto before permit may be issued. t.//D
(Locate building and system; give north arrow and feet Z1d.Z/< f)V
of distance, approximately, to building and closest road.) %vi9r6. Z
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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