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JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK G rre P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
�� Fax (516) 765-1823
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MARRIAGE OFFICER � O �'
—, O all *We e °� Telephone (516) 765-1801
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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. 139-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner AGARABI, ALI
Mailing Address 1 MATT-A-MAR MARINA -
Mailing Address 2 P. O. BOX 1235
City St Zip MATTITUCK NY 11952-0000
Property Address 1 WICKHAM AVENUE
Property Address 2 MATT-A-MAR MARINA
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4739
Tax Map No. section 114.00 block 3 lot 1 .000
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 3/11/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Town of SoutholdApplication No. /3fr"?
Judith T. Terry, Town Clerk t .
510.00 - Residential
Tow n Hall, 53095 Main Road
P. O. Box 1179 525.00 - Non-Residential�� -
Southold, New York 11971 O�
Telephone 0(- 00��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 25;®O
DATE 2 - `'E- '1 3
OWNER NAME: AL' AG4a4viSi
OWNER MAILING ADDRESS: Mick r'I'- A - ?4-12 t A-1 -t&JA-
OWNER PROPERTY ADDRESS: P•o . ISOX 1 2 cD VJI CK AJC'
a 1r i U t! LJ�. % I o sQ
OWNER TELEPHONE NUMBER: rj(6- 2,q tj - 1 7 3 q , -
TAX MAP NO. : Section I ,"1 Block 3 Lot
CROSS STREET: �pv1j(p AoE .
TYPE OF_SYSTEM: 'Septic -Tank- - New Existing
Cesspool ✓, New Existing- - 1�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature of Applicant
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