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JUDITH T. TERRY �� Town Hall, 53095 Main Road
TOWN CLERK _ P.O. Box 1179
REGISTRAR OF VITAL STATISTICSr'T9 Southold, New York 11971
MARRIAGE OFFICER Fax Fax (516) 765-1823
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(516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1658-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MUELLER, MARY A.
Mailing Address 1 6 MIDDLETON ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 6 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0854
Tax Map No. section 33.00 block 5 lot 20.000
Cross Street COUNTY ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.,.
OFFICE4OF THE TOWN CLERK c.SFO(,r��- /
�. r+ Town of Southold CQ Application No. /(O
Judith T. Terry, Town Clerk . a‘i.
Town Hall, 53095 Main Road `p'Y• ` $10.00 - Residential
P. O. Box 1179 cr3 -f-.moi =, ' �% $25.00 - Non-Residential
Southold, New York 11971 O - � ��`
Telephone :Oj l.V0 '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ '! �`•"-
. DATE . 9 1
. OWNER NAME: k I 6-4) 0 u,d) .
OWNER MAILING ADDRESS: v. rt-v 4 . „ , , --4.,,,,„0
OWNER PROPERTY
ADDRESS: , 7(1 N
- t --.V --1\41/,
OWNER TELEPHONE NUMBER: CS it ec, ) 4°77 ® Q S `�I
TAX MAP NO. : Section Block Lot
�Sv cu
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing 4
_ Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: i.A.A.,...)L.4 .0.1%.Lj g
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.)
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,,S'gnatu e of Applicant
__-___---- RECEIVED BY:
Town Clerk's Office
DATE: