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JUDITH T. TERRY � S Town Hall, 53095 Main Road
TOWN CLERK �T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �C �� Southold, New York 11971
MARRIAGE OFFICER �� Fax (516) 765-1823
� ® �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. 1747-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner THOMAS, ALPHONSE & MARGUERITE
Mailing Address 1 P. O. BOX 1070
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1930 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4978
Tax Map No. section 144.00 block 1 lot 14.000
Cross Street PECONIC BAY BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 9/06/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK tc3IFULA' _
Town of Southold �% �•- ea:- Application No. / 7 (4 3
Judith T. Terry, Town Clerk .� Z 0: _ 4r
te ` .G $10.00 — Residential
Town Hall, 53095 Main Road c "Y _ -
P. O. Box 1179 cn 14z.,-,Rt?) • $25.00 - Non-Residential
Southold, New York 11971 4'404-
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Telephone ''�l0 -'Y+�����
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
(
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No'.
Fee $ •
DATE 9-.5-1/
OWNER NAME: )9j /),,e,eihr& ii../v/Medoe4 e /e i ,M, 4 S
OWNER MAILING ADDRESS: S D X / O 70
//j ist%riTve-&v 1 i` /Ms..?
OWNER PROPERTY ADDRESS: /930 S-/q5b e•€.. el)Oh `
/QA- 77-7 Tu e- /c-, / /1 96 .
OWNER TELEPHONE NUMBER: . . 'J ' 07(9 7 ,
TAX MAP NO. : Section ./ catr- Block / - Lot / ti
(„traz
CROSS STREET:
TYPE OF SYSTEM: Septic Tank ✓ New Existing .
Cesspool `/New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ....c.-
LOCATION
�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.)
5 ,e....e.,e.z.zee_ x....7z.e.4.,..2.,
Sig} ture of Applicant
RECEIVED BY:
L/(),U2.-4L__.._,..
own Clerk's Office
•
DATE: ( /9
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