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JUDITH T. TERRY GC. } Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
4#. w:�! Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1950-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BLACKMAN, VIVIAN M.
Mailing Address 1 3735 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3735 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8549
Tax Map No. section 115.00 block 16 lot 20.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/+ • I/4,
_OFFICE OF THE TOWN CLERK FNJ('�
Town of Southold CQG Application No. / so
Judith T. Terry, Town Clerk . �a aid --
Town Hall, 53095 Main Road '4 I $10.00 - Residential
P. O. Box 1179 ', �` $25.00 - Non-Residential
Southold, New York 11971 O , • "-r' ��
Telephone Y0( It% •,°/'�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
fu r
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/Od
64)
DATE 7—/7-
OWNER NAME: Vi \1/M A) 1 • , LA-"eci J-o f
OWNER MAILING ADDRESS:373_5- 4, Ah--&
OWNER- PROPERTY ADDRESS: G�
OWNER TELEPHONE NUMBER: c;;2911�,5"-- '9
TAX MAP NO. : Section LEST 6 6 Block it -C O Lot �c O , ae
CROSS"STREET: ), Vre,4c-Z,Z
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: -� � - •°
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/Li
/ Signature-o- • pplic
RECEIVED BY:
own Clerk's Office
DATE:
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