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cjr2 filY7 Town Hall, 53095 Main Road
P.O. Box 1179
pits Southold, New York 11971
JUDITH T.TERRY -- a�.`•. FAX(516)765-1823
TOWN CLERIC TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 111-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner BEDELL VINEYARDS, INC.
Mailing Address 1 36225 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 36225 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7537
Tax Map No. section 97.00 block 1 lot 25.001
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/86
Issue Date: 8/28/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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'-4. 'v'OFFICE OF THE TOWN CLERK r ('\)FFO�
Town of Southold o - CQG Application No. ye///
Judith T. Terry, Town Clerk 'r;``. : �►�'
$10.00 - Residential
Town Hall, 53095 Main RoadP. O. Box 1179 cn �� r"`
., ,.. .,�. • $25.00 - Non-Residential
Southold, New York 11971
Telephone : .( *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ .S Qo
DATE
OWNER NAME: '
OWNER MAILING ADDRESS: S(0a--"a-5 ('1 . R-o1c
CsYK�Ffo6ov t OA 1 k_°t 3�
OWNER PROPERTY ADDRESS:
�3 SSE-�oC�cllF� N)\-1
OWNER TELEPHONE NUMBER: (51(c,) S 37
TAX MAP NO. : Section ./ Block Lot
CROSS STREET: g(Z--41)G Le5rL7
TYPE OF SYSTEM: Septic Tank ✓ New _ Existing
Cesspool New • Existing
Residential Non-Residential ✓
DATE OF PREVIOUS PUMP-OUT: 19.
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.)
- .ture of Applicant
RECEIVED BY: „ .,...,
PIU UTroWrPCIerk's Office •
DATE : GCS Ural°
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