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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
Fax (516) 765 1823
MARRIAGE OFFICER ® •
',y®1 ��® .�� Telephone (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. 3024-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ODDON, RICHARD AND EILEEN
Mailing- Address 1 2455 WESTPHALIA ROAD-
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2455 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8488
Tax Map No. section 114.00 block 10 lot 23.000
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK oS� FHU(
Town of Southold �� Application No.3d�q
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road
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$10.00 - Residential
P. O. Box 1179 v' •
;� moi $25.00 - Non-Residential
vcrSouthold, New York 11971 O ®_ y:'z.: ��
Telephone *14% #O '1•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE51-1/ � �
OWNER NAME: i 6de!o U /1
CaCtein
OWNER MAILING ADDRESS: `-L SS Wes-y-1,6:14 ermd
I 1 Aal 87
OWNER PROPERTY ADDRESS: %-i}'I,_,
OWNER TELEPHONE NUMBER: 44 rc- /��
TAX MAP NO. : Section Hi/ Block /e Lot „P.-3
CROSS STREET: .
TYPE OF.-SYSTEM:-- -Septic Tank- - - New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1///f/ j
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. BY:: -
Town Clerk's Office =
DATE:
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