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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS / Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ®�
® $6
�,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. 3080-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VICTORIA, PETER J.
Mailing Address 1 P. O. BOX 1130
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1295 ELIJAH LANE
Property Address 2 •
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8944
Tax Map No. section 108.00 block 4 lot 7.007
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/05/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3081-R
Fee $ ----- _ Residential X Non-Residential
10.00 -
______ Septic Cesspool
X
New Existing X
Name Of Ownep-
POOLE, NANCY -
__ ________________
Mailing Address 1
1111 _
• ...
OFFI'CE OF THE TOWN CLERK /c3VFF�(,� '=
Town of Southold � _ CQG Application No. c30(PC)
•
Judith T. Terry, jown Clerk
Town Hall, 53095 ain Road
.0 1 $10.00 - Residential
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P. O. Box 1179 (13 �` ' ; $25.00 - Non-Residential
Southold, New York 11971 O%® t $
Telephone N
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE ,'" 3 9-3
.r.POWNER NAME: t U fetbacti4
OWNER MAILING ADDRESS: -Po- x I 1Z 0
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OWNER PROPERTY ADDRESS: 1,D4 j -
/I)117PT1e /Uy-
OWNER TELEPHONE NUMBER: 614v-c9f p'-- j-'tfy
TAX MAP NO. : Section /OF Block Lot 7
CROSS STREET: ,fej2_
TYPE OF SYSTEM: Septic Tank New Existing x
Cesspool New Existing X,
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: .411--
LOCATION
7S-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: ,4
Towri Clerk's Office
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DATE: cI �'3
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