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OFFICE OF THE TOWN CLERK ' •SWFIV(
Town of Southold •� �� C�
Judith T. Terry, Town, Clerk '*4 %
Town Hall, 53095 Main Road $ '"`-' .
P. O. Box 1179 u' -- `k'`"` " •
Southold, New York 11971 `0,4 '"' xA; ' �•�,
Telephone
_�l ^
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1 Residential XXX
Non-Residential
Fee $
Septic Cesspool XXX
- -NAME OF OWNER: David Newton
OWNER MAILING ADDRESS: 680 Deep Hole Drive, P .O . Box 947
Mattituck, New York 11952 ;'
OWNER PROPERTY ADDRESS: same •
,:
O
OWNER TELEPHONE NUMBER: none
TAX MAP NO. : Section 115 Block 12 Lot 9
CROSS STREET: New Suffolk Avenue
• TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XXX New Existing XXX
- _ - Residential XXX Non-Residential
DATE OF- PREVIOUS PUMP-OUT: None ( constructed in 1959)
",—..
Judith T. Terry
Southold Town Clerk
DATE: August 15 , 1986
(TOWN SEAL)
OFFICE OF THE TOWN 'CLERK gc\ FOL - = "
Town of Southold e4-% Application No.` -
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road 8 Residential
P. O. Box 1179 cn ; Non-Residential
Southold, New York 11971
Telephone
-VI 3E40
- (516) 765-1801 r<~� 'k
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee v.
DATE
OWNER NAME: Area rea ' D
OWNER MAILING ADDRESS:- I b,), e 91,7) M-Tripirox/ V `.�
eye e
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 4>114
TAX MAP NO. : Section ng Block if ;2, Lot
a CROSS STREET: p d Lifilv!/ 0@ e Jf ?y�.,/`
/Si4111
TYPE OF SYSTEM: Septic Tank %' New Existing J 'J f / c
Cesspool r New Existing
Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT: A/1 44
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.)
Aolk
4-1n4/ filt
Signatr- of Applicant
RECEIVED BY-: 0 �J
Rik Town Clec's Offi e
DATE: S /yA. 1
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