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ELIZABETH A.NEVIL E y� Town Hall, 53095 Main Road
TOWN CLERK y - P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
I- MARRIAGE OFFICER ,y �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER "'/ ��® Telephone (631) 765-1800
FRE DOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF HE TOWN CLERK
TOWN OF SOUTHOLD
S UTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL -
0 eration Permit No. 4236-R Residential x Non-Residential
e $ 10.00 New x Existing
N me Of Owner JOHN BEDELL
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M iling Address 1 375 WAMPUM WAY
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M iling Address 2
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C ty St zip SOUTHOLD NY 11971-0000
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P operty Address 1 375 WAMPUM WAY
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operty Address 2
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C ty St zip SOUTHOLD NY 11971-0000
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o ner Telephone No. 631-765-9404
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T x Map No. section 87,00 block 2 lot 37.000
Cross Street WIGWAM WAY
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Issue Date: 1/28/04 Elizabeth A. Neville
-------- Southold Town clerk
(TOWN SEAL)
M
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD 0�, COG Application No.
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179 22
sOUTHOL,D,NEWYORK11971 • $25.00 - Non-Residential
Fele-phone -
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVED
APPLICATION
for DEC - 9 2003
'
OPERATION PERMIT Southold Town Clerk
SEPTIC TANK or CESSPOOL
Operation Permit No. q�2o ,
Fee $
DATE
OWNER NAME: ,��Xon
OWNER MAILING ADDRESS:
i 7
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
1 Lc'r3 ?7 0'2-- 39
TAX MAP- NO. : Section,67q /® co 1397 Y Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank 1GC0q,/ Ne Existing
Cesspool G� . k� New Existing
Residential Non-Residential
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.)
Sign" ur of Applicant
RECEIVED B,
wn Clerk's Office
DATE: