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Town Hall, 53095 Main Road
1 P.O. Box 1179
�a,„. Southold, New York 11971
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JUDITH T.TERRY - ® i��i FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1166-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOSHIER, FRANK J
Mailing Address 1 235 23RD AVENUE
Mailing Address 2
City St Zip VERO BEACH FL 39262-0000
Property Address 1 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 407-569-3072
Tax Map No. section 143.00 block 2 lot 21 .000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/20/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•OFFICE OF THE TOWN CLERK od,
taE
Town of Southold
Application No. Me 0
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a ;-« `''� :'� Residential
P. O. Box 1179 Non-Residential
Southold, New York 11971 O "c- ••
Telephone Oj y `��
(516) 765-1801
TOWN OF SOUTHOLD
MAY 1196SSOUTHOLD WASTEWATER DISPOSAL DISTRICT
/4,4APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $ /0.,030
•
DATE
OWNER NAME: RI/UK /110-CP /
OWNER MAILING ADDRESS: -3,
OWNER PROPERTY ADDRESS: MM.4, /
4')19-Tr/ cleA; 19`;-y //�s
OWNER TELEPHONE NUMBER: yb — 5-6 9 -- 3 0`7
TAX MAP NO. : Section / Block dl Lot dl
CROSS STREET: /}7A 1/V
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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 B •
'' Town Clerk's Office
DATE: � J 2 019��