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JUDITH T. TERRY ; ` Town Hall, 53095 Main Road
TOWN CLERK P.O.T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �• Southold, New York 11971
✓ Fax (516) 765-1823
MARRIAGE OFFICER O •
,10 ) j �0•� 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. 2088-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DOBKIN, GARY J.
Mailing Address 1 67-15 102 ND STREET
Mailing Address 2
City St Zip FOREST HILLS NY 11375-0000
Property Address 1 R.O.W. OFF COX NECK ROAD
Property Address 2 P. O. BOX 1114
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 918-997-0046
Tax Map No. section 113.00 block 12 lot 10.001
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 3/29/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK, cOFU1A- -
Town of Southold _:3 e, Application No.c ?
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
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P. O. Box 1179 u' `�® `' $25.00 - Non-Residential
Southold, New York 11971 O '
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Telephone : 1 t
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 06-b-3
OWNER NAME: AVJ ( 5k f 1/
OWNER MAILING ADDRESS: 7-45- /6o-w/3 6
T 6i &c i (i'L�s Al `/ l 13
- --- ER PROPERTY ADDRESS: /Q•--O /30( i/ f
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OWNER
' ZOWNER TELEPHONE NUMBER: (7/x') -W7d FZ (2576) �IcP`l/c~7
TAX MAP NO. : Section /) Blo k /02 Lot /6' /
CROSS STREET: C 0-eV 141
TYPE OF-"SYSTEM: Septic Tank --New New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /l/3lQY
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.)
•
Sig ture of Applicant
RECEIVED BY: - ---
Town Clerk's Office
DATE:
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