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13 m Town Hall, 53095 Main Road
4 P.O. Box 1179
_ ®� *4'4 �! Southold, New York 11971
JUDITH T.TERRY �o' 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. 957-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CARLIN, FRANK E.
Mailing Address 1 P. O. BOX 1182
Mailing Address 2 MAIN ROAD
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4014
Tax Map No. section 125.00 block 3 lot 14.000
Cross Street MAIN ROAD ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 12/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
a r
Of
OFFICE OF THE TOWN CLERK ° so COMA'
Town of Southold �� CQG Application No. 5-7-7
Judith T. Terry, Town Clerk ,
*� .0
Town Hall, 53095 Main Road o e, Residential
P. O. Box 1179 f-.+ � � � Non-Residential
Southold, New York 11971 O•&•O ,F ,' ���/,
Telephone 1 * y1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
®V S OPERATION PERMIT
ael 4a A-4 SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /
DATE ////07,/,/ s
OWNER NAME: /24//X'
OWNER MAILING ADDRESS: //,f04- Mi "eel; 100X 1/
CK.
OWNER PROPERTY ADDRESS: $ �� i S 430
OWNER TELEPHONE NUMBER: — geV-- o / V
TAX MAP NO. : Section/ L ` 3.J Block Lot
CROSS STREET: /f4—) /\J lea ���.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residentialf Non-Residential
DATE OF PREVIOUS PUMP-OUT: / v� 5 i fi' 7
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.)
4.EZ
Signature of Applicant
RECEIVED BY: /144
Town Clerk's Office
DATE: 4:V/3/6-
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