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JUDITH T. TERRY �� O Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS tT Southold, New York 11971
MARRIAGE OFFICER y Fax (516) 765-1823
® ®" � Fax
(516) 765-1801
46 1% 009
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1695-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BANNON, DENNIS R.
Mailing Address 1 P. O. BOX 920
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 855 MARYS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5559
Tax Map No. section 140.00 block 2 lot 1 .000
Cross Street HAMILTON AVENUE
Date Of Last Pump Out 0/00/79
Issue Date: 6/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cvFFO(,(r�'-
Town of Southold �� ;< CQG Application No. / 7.
Judith T. Terry, Town Clerk ,7 .., y
Town Hall, 53095 Main Road E . $10.00 - Residential
P. O. Box 1179 crs W.1'4' ► �` $25.00 - Non-Residential
Southold, New York 11971 O ®. $'`"-"'0*.$
Telephone 01 ze.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE `'fl di 30 Iqq l
OWNER NAME:
SE.rt,f'1.1 g tR • -bane)0'r1
OWNER MAILING ADDRESS: .O. -6Ox. 92.0
614*-K. 1 1.915.
OWNER PROPERTY ADDRESS: Z55 `tfCU-1. , ('Reit. .
rnrt. ). 11a6"a-a
OWNER TELEPHONE NUMBER: (SI(o> Alt- 5'S641
TAX MAP NO. : Section IN 0 Block Lot
CROSS STREET: 1 &m% Him AveinkuL,4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ / New Existing V
Residential ' Non-Residential
DATE OF PREVIOUS 'PUMP-OUT: J L,y-w
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:
own Clerk's Office
DATE: 09/
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