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F74,�� Town Hall, 53095 Main Road
ec n O , P.O. Box 1179
P"i Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1211-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner URIST, ARNOLD A.
Mailing Address 1 URIST, LISOLETTE H.
Mailing Address 2 P. O. BOX 1436
City St Zip MATTITUCK NY 11952-0000
Property Address 1 300 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4290
Tax Map No. section 6 block -298-- lot 44.290
/to _ _mss__
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 8/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold 3 C'� Application No. j
Judith T. Terry, Town Clerk I ;�;��'�����'�'�� G pp /�j
~ ��rt' ` 1 $10.00 - Residential
Town Hall, 53095 Main Road
P. (13 '`t $25.00 - Non-Residential
O. Box 1179 � .�
Southold, New York 11971 4 ®_ tj';O �J
TelephoneOI `j�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: A 0 Lb A. u 1 5 i 2. L ISt. T I E
N.
OWNER MAILING ADDRESS: p . 0. (30X k/,- 3C,
OWNER PROPERTY ADDRESS : •QQ A00l kos4f..iP
i -r-L)Ci4.
OWNER TELEPHONE NUMBER: h 0 (, 2 ? et*
29 O
TAX MAP NO. : Section 3 Block ' Lot
CROSS STREET: C? /
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing x
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1~'q
`! c OCA
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.)
L
Signature of Applicant
RECEIVED BY:
wn Clerk's Office
DATE: �0
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