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JUDITH T. TERRY 0 tot` Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS rrt
•W' Southold, New York 11971
MARRIAGE OFFICER y , Fax (516) 765 1823
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1732-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JOHNSON, BRUCE
Mailing Address 1 P. O. BOX 914
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5968
Tax Map No. section 103.00 block 11 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK , 0 •
c�IFD(,r�'-
Town of Southold &*% CSG; Application No. ( 2 3.)
Judith T. Terry, Town Clerk t;ri0 `
Town Hall, 53095 Main Road g3;"
,; r ��� $10.00 - Residential c�
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P. O. Box 1179 �;,`"��; �;'� $25.00 - Non-Residential
Southold, New York 11971
Telephone ( `A�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 6Eqf (470s (�
OWNER MAILING ADDRESS: t (1) 60-); 5/9/
011/ '
OWNER PROPERTY ADDRESS: / r
OWNER TELEPHONE NUMBER: 7c ` ' O V
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TAX MAP NO. : Section /O. Block // Lot
CROSS STREET: r'-),c:: \ 'RD
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 2 (f-2
LOCATION MAP: Must be attached hereto b fore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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S•gnatur o"" ' pplicant
RECEIVED BY:
Town Clerk's Office -
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DOTE: O/7
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