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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold,REGISTRAR OF VITAL STATISTICS � Sou + New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
�® ��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. 1738-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ZEISS, HENRY AND VIOLA
Mailing Address 1 1450 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1450 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8492
Tax Map No. section 115.00 block 12 lot 20.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OI1FICE OF THE TOWN CLERK cOFOC,Ir�'=
Town of Southold 4 . . Application No.
Judith T. Terry, Town Clerk $10.00 - Residential
Town-Hall, 53095 Main Road Y`
P. O. Box 1179 ' �" �}= h�i $25.00 - Non-Residential
Southold, New York 11971 O ,®, :' °�`
Telephone '5'4:1-'4'7 •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O. as
DATE ,(2.r...tai-
OWNER' NAME: • 91-"Zi ;
2 .��
OWNER MAILING ADDRES /'
710-
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section //`J Block /off Lot c7c'
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CROSS STREET: f` �.. ,, Q,�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: /161//K
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.)
Signatu211A. plicant
RECEIVED BY:
Town Clerk's Office
DATE: QA,7//
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