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WAt;+ Town Hall, 53095 Main Road
,�® `` � P.O. Box 1179
� ��! Southold, New York 11971
JUDITH T.TERRY ® ` ►!'�" FAX(516)765-1823
ri it TELEPHONE(516)765-1801
TOWN CLERK
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. 1378-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TROYAN, JOHN, JR & ELIZABETH
Mailing Address 1 P. O. BOX 1024
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 CARDINAL DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8855
Tax Map No. section 115.00 block 4 lot 21 .000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK scl \VF .'= a
it Town of Southold ACSG- Application No. -3 �o
Judith T. Terry, Town -Clerk
Town Hall, 53095 Main Road ` _ -� } $10.00 - Residential
p. 0. Box 1179 040 $25.00 - Non-Residential
Southold, New York 11971 0 ,� •
�`
Telephone Q( st
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ n ;
DATE o?/ciTi90
OWNER NAME: ,./0/7 0-1/26( a�' /j may .J/t - •
•
OWNER MAILING ADDRESS: "g' ,�.i/ /Ga/
— 7/.? 7G1J - /// :
/ - -
OWNER_ PROPERTY ADDN)ESc •
_..//7/-;7/7 .71/1<";/<, %q //9J-4 -
OWNER TELEPHONE NUMBER: 6279P (F-43`0--
00
TAX MAP NO. : Section ila Block O Lot da
CROSS STREET: C«,; �c
TYPE OF SYSTEM: Septic Tank New, Existing
Cesspool New Existing
Residential i- Non-Residential
DATE OF PREVIOUS PUMP-OUT: j�/i ?
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.)
al._ t
Signature of pplica t
RECEIVED BY:
' Office
Town Cler s 0 ce
DATE: d- c-1?)
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SURVEY FOR Q'
WILLIAM WOLFMULLER a INEZ WOLFMULLER u
LOT NO. 54, " MATTITUCK ESTATES "
MATTITUCK GUARANTEED TO: QO
TOWN OF SOUTHOLD SOUTHOLD SAVINGS BANK �Q-
SUFF. CO., N.Y. THE TITLE GUARANTEE CO.
SCALE: 1"= 40'
APR. 27, 1967 &eid/r
PROFES • • EN ►•EER 'AND NOTE ■ = MONUMENT
L AND SURVEYOR,N.Y.S.UC.NO.12845
RIVERHEAD, N.Y.