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t • Town Hall, 53095 Main Road
o' P.O. Box 1179
-__ iii ��0 Southold, New York 11971
JUDITH T.TERRY ---
- 40. FAX(516)765-1823
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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. 1528-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MULLEN, EDWARD J.
Mailing Address 1 1305 TOWN HARBOR LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1305 TOWN HARBOR LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5460
Tax Map No. section 66.00 block 1 lot 16.000
Cross Street HOEY LANE
Date Of Last Pump Out 0/00/00
Issue Date: 9/25/90 Judith. T. Terry
Southold Town Clerk
(TOWN SEAL)
I"„
OFFICE OF THE TOWN CLERK •c�FFEV(
Town of Southold CQG',, Application No. lj^�
Judith T. Terry, Town Clerk �r � f/
$10.00 - Residential
Town Hall, 53095 Main Road
p. O. Box 1179 cry '` Y `„,4= i $25.00 - Non-Residential
Southold, New York 11971 Oji' 3s” 0�•',,
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Telephone •
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permiti No.
Fee $ •
DATE 9' —
'OWNER NAME: L-.asd-R J M cm_ •
OWNER MAILING ADDRESS: /3Q.5 7 W/U /-1 60c)2 AA/tiG
07#01-6 , A) >' 1 / 97 1
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section (p Block / Lot /4
CROSS STREET: 14 Qe� /
TYPE OF SYSTEM: Septic Tank New Existing X
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Af0/1) -
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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Signatu of Applicant
RECEIVED BY': "71/ / "tj�
Town Clerk's Office
DATE: 9-
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