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JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK �+ P.O. Box 1179
• Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 4 O � `� Fax 516
MARRIAGE OFFICER ® ,� ( ) 765-1823
.f�® ��®��l Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3069-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ADAMS, EDWARD
Mailing Address 1 P. O. BOX 622
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4175 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8637
Tax Map No. section 115.00 block 4 lot 34.001
Cross Street MARATOOKA
Date Of Last Pump Out 0/00/00
Issue Dater 7/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .COFU1 -
Town- of Southold �� ,;- CQ ' Application No. 36(0?
Judith T. Terry, Town Clerk ?ek e4' .' �►
Town Hall, 53095 Main Road 7 $10.00 - Residential
P. O. Box 1179 i %" ' $25.00 - Non-Residential
Southold, New York 11971 ���`
Telephone : ( ��
(516) 765-1801
TOWN OF SOUTHOLD
_ SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION - - - -
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ -- •
-
DATE O P
i OWNER NAME: ' x/95
,\ OWNER MAILING ADDRESS: 00X G.2 2 / e cYoc`o c i /
ti!477 7&cc4l =- 952 NIX
- .- OWNER PROPERTY 'ADDRESS: -- 5449, /as ,;',,63 au
I
! f OWNER TELEPHONE NUMBER:- 5/6- 2:91 —5163)
TAX MAP NO. : Section /16— Block — Lot
CROSS STREET: C p%4/e12 O. /1/eedEd /(-1/ iaa/l-I
TYPE OF SYSTEM: Septic- Tank New Existing V
Cesspool New Existing
Residential - - Non-Residential
DATE OF PREVIOUS PUMP-OUT: J2 /1'€ c /99-3
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.)
6/(Ala/21-ej daZisixtv
Signature of Applicant
RECEIVED BY:
- Town Clerk's Office -
DATE: ,
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