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Town Hall, 53095 Main Road
P.O. Box 1179
_ � •�'' Southold, New York 11971
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JUDITH T.TERRY = ®i �.,,.°� TELEPHONE
TOWN CLERK (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. 917-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOOKER, MARY L. AND OTHERS
Mailing Address 1 755 ROGERS AVENUE
Mailing Address 2
City St Zip BROOKLYN NY 11226-0000
Property Address 1 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 718-462-5595
Tax Map No. section 141 .00 block 3 lot 44.000
Cross Street FACTORY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ,;c0FOU,C'- j7
Town of Southold �� , K Dom'; Application No.
Judith T. Terry, Town Clerk a y
Town Hall, 53095 Main Road ;< 1 Residential
P. 0. Box 1179 (1' rP;.�, r: H
Non-Residential
3(Rif Southold, New York 11971 O `- ��•�
Telephone �( yltr
(516) 765-1801
RECEIVED: TOWN OF SOUTHOLD
011 17 1980 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Town Clerk Southbreq
APPLICATION
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OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /t / 0 0
DATE 0C'` /' - / Z
/14/ /&7 L Ao 6 �LLi L/3o o•,2:7e_ w in a__D .,,v
OWNER NAME: C t 0 LPt, 6,4-22./C / T!/�/L�S'�� oS //t /36d Cz
OWNER MAILING ADDRESS: t'`l et -ZZvc, // w6°. l' � S r
/r}4-A.ZA9,4/ 611// 61-06/cLyj 1,4-2tY i-0Za2414 /e JE T f i y; TGi o L 7S`�✓,2 �j�S A
OWNER PROPERTY ADDRESS:'" —
/ 'I, n- II q�r
OWNER TELEPHONE NUMBER: //g 46°2' .5 µ,,,yr£ °r2't
TAX MAP NO. : Section `_ - Block 3 Lot 47Lel
CROSS STREET: a4 1.4 Id
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Y,/ New Existing
Residential i Non-Residential
DATE OF PREVIOUS PUMP-OUT: 11 �Y
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.)
0, 11[-0 J2J
44C21)
ignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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/41 -3-44
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