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JUDITH T.TERRY d •• Town Hall,53095 Main Road
TOWN CLERK g t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS •- O ��, Southold,New York 11971
Fax(516)765-1823
MARRIAGE OFFICER �� ® ell,
RECORDS MANAGEMENT OFFICER g ED �,d Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3246-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MORTENSEN, NICHOLAS
Mailing Address 1 1560 BAILIE BEACH ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1560 BAILIE BEACH ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9359
Tax Map No. section 99.00 block 3 lot 11 .011
Cross Street SOUND VIEW AVENUE
Issue Date: 9/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKFOur
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Town of Southold 0 �pG.\ Application No. L/4
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road g $10.00 - Residential
P. O. Box 1179 cn $25.00 - Non-Residential
Southold, New York 11971
Telephone 1110 IP"
(516) 765-1801
.TOWN OF SOUTHOLD
-SOUTHOLD WASTEWATER DISPOSAL DISTRICT - ,
APPLICATION
SEP
2 1994
for , So
OPERATION PE-RMIT
•
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 9172
OWNER NAME: /24 `As no,o`"4/os�-✓
OWNER MAILING ADDRESS: /4"6O ./g4/Zig .cic1 2�
.A44 -i%�em6 %I/ a/VAri�%�v
OWNER PROPERTY, ADDRESS: 2--.4ryzz_-
OWNER TELEPHONE NUMBER: 0?,91f ,r9
TAX MAP NO. : -,Section 99 Block .� Lot /2d47
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New. Existing
Cesspool New Existing
Residential 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.)
•
Signature of Applicant
RECEIVED BY:
Towns C erk's Office
DATE: ' o . 9 L)
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