HomeMy WebLinkAboutAgarabi OFFIsCE Of THE TOWN CLERK ' .c3VFFUC,('
Town of Southold
Judith T. Terry, Town Clerk y`
Town Hall, 53095 Main Road ..
P. O. Box 1179 ;�^• •�
Southold, New York 11971 ' O •�
Telephone 4 AI&
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. NR 10 Residential
Fee $ 25.00 Non-Residential: XX
Septic Cesspool XX
NAME OF OWNER: Dr. Ali Agarabi
OWNER MAILING ADDRESS: 306 Prospect Avenue
Sea Cliff, New York 11579
OWNER PROPERTY ADDRESS: Wickham Avenue (P.O. Box 1235) - Wickham Road Marina
Mattituck, New York 11952 c/o Matt-A-Mar
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OWNER TELEPHONE NUMBER: 516-2984739—
TAX
16-2984739TAX MAP NO. : Section 114 Block 3 Lot 1
CROSS STREET: Bayer Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential XX
DATE OF PREVIOUS PUMP-OUT: August 29, 1986
Judith T. Ter
Southold Town Clerk
DATE: September 25, 1986
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(TOWN SEAL) --
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OFFICE OF THE TOWN CLERK s\FFOUre,- Q
Town of Southold �� �zrC�G Application No./(//1 /o
Judith T. Terry, Town Clerk 04. Residential
Town Hall, 53095 Main Road os P. 0. Box 1179 cn ® rit : Non-Residential
Southold, New York 11971 OO �0�,��
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
jay-_ Z.2_
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No;NI/O
Fee $ 25 : 00
DATE September 22, 1986
OWNER NAME: Dr. Ali Agarabi
OWNER MAILING ADDRESS: 306 Prospect Avenue
Sea Cliff, New York 11579
OWNER PROPERTY ADDRESS: Wickham Avenue P. O . Box 1235
Mattitizck, New York 11952
OWNER TELEPHONE NUMBER: ( 516) 298-4739
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TAX MAP NO. : Section Block � Lot --
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 8-29-86
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.)
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/ Signature- ..,,App ' ant
RECEIVED BY: 4cCr
Town C rk's 0 u ice
DATE: , o?S ,/9
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