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JUDITH T. TERRY r � .
® Town Hall, 53095 Main Road
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P.O. Box 1179
®
TOWN CLERK
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Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ��` Fax (516) 765 1823
MARRIAGE OFFICER ®y® ®� � Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1934-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WARREN, MILDRED I.
Mailing Address 1 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8141
Tax Map No. section 115.00 block 12 lot 6.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
, III I
OFFICE OF THE TOWN CLERK caFDC,j-
Town of Southold c'6, Application Application No -='
Judith T. Terry, Town Clerk .` h.,
Town Hall, 53095 Main Road >: :'C. I $10.00 - Residential
P. O. Box 1179 cry $25.00 - Non-Residential
Southold, New York 11971 O ®s
Telephone • 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /61,00
DATE
OWNER NAME: /q,/
OWNER MAILING ADDRESS: ) , if 1---fe, J- i 04' 1 v6
4/1-r7/ AA-' l fq�v
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: ,-)"9 / 1"/.l
TAX MAP NO. : Section // 1--- Block r v Lot
CROSS STREET: Uf ( / S OF fU i-X ,6Ve •
TYPE OF ,SYSTEM: -Septic Tank - New Existing
.
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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: v7
_ _ c IVrkt* Office i
DATE: JUN 19 1992 -
Southold Town Clerk
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