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JUDITH T. TERRY ' Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ` Southold, New York 11971
MARRIAGE OFFICER . s O �, Fax (516) 765-1823
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1914-R Residential X Non-Residential
Fee $ 10.00 - Septic Cesspool X
New Existing X
Name Of Owner NEEFUS, JAMES F. JR.
Mailing Address 1 BOX 505
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 165 SAILORS NEEDLE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-765-2593
Tax Map No. section 144.00 block 5 lot 27.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/01/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE.OF THE TOWN CLERK �c0FO1.,- :=
Town of Southold V� y CV-.' Application No.
Judith T. Terry, Town Clerk �� , i.-..'!. itv-.
Town Hall, 53095 Main Road f, ` $10.00 - Residential
P. 0. Box 1179u' "'�•_ .� �?-: '���` $25.00 - Non-Residential
Southold, New York 11971 O ` ' �/`
Telephone ( ���
(1116) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT"
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: I,,&d-"0 /1
OWNER MAILING ADDRE S: 6 ( 'X�� gelew.24,60 /
,s-vv, if/ 97/
OWNER PROPERTY ADDRESS: i‘45- .
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/- 49,5'..
OWNER TELEPHONE NUMBER: ,c57
TAX MAP NO. : Section pig Block `j- Lot .2 7
CROSS STREET: _� ,,�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool o New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7/79.7
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.)
,„, a /' , -®.
Signature f Applicant
RECEIVED BY:
Town Clerk's Office
DATE: