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JUDITH T. TERRY v Town Hall, 53095 Main Road
TOW11T CLERK ® ,
P.O. Box-1179
ySouthold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER ,�1 Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ®1 ,
FREEDOM OF INFORMATION OFFICER '',•ilo„air �'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3252-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MORMILE, ARTHUR AND MARIAN
Mailing Address 1 P. O. BOX 698
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4714 GREAT PECONIC BAY BLVD.
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-8708
Tax Map No. section 128.00 block 4 lot 16.000
Cross Street DELMAR DRIVE
Issue Date: 9/16/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cVFFOU(
Town of Southold �� CQG= Application No. ,.5;>9--
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cr3 ' • $25.00 - Non-Residential
Southold, New York 11971 O 0��'`,
Telephone 0I. �� '0,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
IRBCEIVED
APPLICATION
• - for
SEP 1 6 1994
Southold Town Clerk-
OPERATION PERMIT
SEPTIC, TANK or CESSPOOL
Operation Permit No.
Fee $ 0 '00
•
DATE
OWNER NAME: 6kdiagilNa44/ i
OWNER MAILING ADDRESS: 7%0 40/ cper / i/, /- / //e3-A
OWNER PROPERTY ADDRESS:pfae.--- gkee
OWNER TELEPHONE NUMBER: Q'e'- g7 Df .„
TAX MAP NO. : Section /=2 6 Block - 9 Lot —1
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential r Non-Residential
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.)
024414) /2/4PaiVniik
Signature of Applicant
RECEIVED BY: `_�/j 6
T w Clerk's Office
DATE: 1 ' 9 `�
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