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JUDITH T.TERRY ® `. 3f{r Town Hall, 53095 Main Road
TOWN CLERK k ff".% P.O.Box 1179
` �=;z �' �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �> `'
iv '' �,. // Fax(516)765-1823
MARRIAGE OFFICER ® � Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER 1 19„,
FREEDOM OF INFORMATION OFFICER if
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3361-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DEGRAFF, J. GARRETT JR. &
Mailing Address 1 MARGARET
Mailing Address 2 163 ETON PLACE
City St Zip WEST HEMPSTEAD NY 11552-0000
Property Address 1 ALDRICH LANE EXT.
Property Address 2 (P. O. BOX 1496)
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-481-2731
Tax Map No. section 112.00 block 1 lot 11 .000
Cross Street NORTH ROAD
Issue Date: 6/28/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
ei
`OFFICE OF THE TOWN CLERK c�V�FO(,r .
Town of Southold � CQ ' Application No. 36(-
Judith T. Terry, Town Clerk .� i4
Town Hall, 53095 Main Road 8 „ $10.00 - Residential
o
P. O. Box 1179 t ;'
$25.00 - Non-Residential
Southold, New York 11971
Telephone 0 * I0-
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE U/ l 1 ) l 1S
OWNER NAME: - lT ' 1 - , flfr 6 -ft iS . 1�(j �F, T- .
OWNER MAILING ADDRESS: I63 E>IbA) P c
R)e S-i 44 9 N) 1
OWNER PROPERTY ADDRESS: p` � . &&xI 'C ?b ✓��iD��C �I1- ) :, c ,
OWNER TELEPHONE NUMBER: („\---10 / 7 i31 6-71(j )in-c{
TAX MAP NO. : Section l 1 Z Block I Lot 11
CROSS STREET: jOe.)/04-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool a✓ 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.)
90,xxstlaSignature of Applicant
RECEIVED BY:
Town Clerk's Office _ __ _ __ _ _
DATE:
r
J.Garrett De Graff,Jr.
163 Eton Place
West Hempstead,NY 11552
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