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Town Hall, 53095 Main Road-
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P.O. Box 1179
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JUDITH T.TERRY
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TOWN CLERK FAX(516)765-1823
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. 1302-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VL'HELEN, JOHN H.
Mailing Address 1 575 RILEY AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 575 RILEY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9390
Tax Map No. section 143.00 block 4 lot 15.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 11/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWNICLERK •��VFOU, =
Town of Southold c c'- CQ • Application No. /30 _
Judith T. Terry, Town Clerk � r h ,fai, $10.00 - Residential
Town Hall, 53095 Main Road � ac � z
P. O. Box 1179 r "�^`} ; $25.00 - Non-Residential
Southold,oNew York 11971 O `'� °.u '°,. ���`
o Telephone01 ��� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D;z)D °
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DATE //- �/ �' 83
OWNER NAME: 3DFirS LG1'-T1 •
OWNER MAILING ADDRESS: Se 77,5 .RJL c--
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OWNER PROPERTY ADDRESS: _ , 4,/41111/.3'
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OWNER TELEPHONE NUMBEf1 6_/C) 9 8,— 9 3 g`O
TAX MAP NO. : Section /g,3 Block V Lot /c
CROSS STREET: 04 ,/ 41./L1 •
TYPE OF SYSTEM: Septic Tank New Existing ,
Cesspool ✓ , New Existing /7
Residential V Non-Residential
-LOCADATE OF PREVIOUS PUMP-OUT: 4/6 /?z CbR1), j , ;yoe To /,2- B.3—
LOCATION
TION 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.)
'Sig at re of Applicant •
0
RECEIVED BY:
Town Clerk's Office
DATE:
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