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JUDITH T. TERRY :c=s— Town Hall, 53095 Main Road
TOWN CLERK c ) (%, P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .� Southold, New York 11971
MARRIAGE OFFICER ® O ;i!. Fax (516) 765-1823
Vigo ,s�, Vijo 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. 128-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner HOMAN, JAMES AND ELIZABETH
Mailing Address 1 P. O. BOX 971
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 CEO. BRAUN OYSTER CO., INC.
Property Address 2 MAIN ROAD
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6700
Tax Map No. section 103.00 block 1 lot 3.000
Cross Street STILLWATER AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE QF THE TOWN CLERK 9SgFO(,r '
Town of Southold �� s . 6Q -1 Application No. /0--r
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road 8 -�
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? $10.00 - Residential
P. O. Box 1179 cu-3 ' 4 � i ; $25.00 - Non-Residential
Southold, New York 11.971 � �0�'�
Telephone : .( NN
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(516) 765-1801
TOWN OF, SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 2,J�
DATE
OWNER NAME: gonl 4 N .! 01-144 E S * CLiZ,t tae-
OWNER MAILING ADDRESS: l3p q' /
OWNER PROPERTY ADDRESS: keo 4 ,J
C' v7 C�4D u d-
OWNER TELEPHONE NUMBER: to 70 d
TAX MAP NO. : Section 1 0 3 Block I Lot 3
• CROSS STREET: 372t /4-re v e -
TYPE OF SYSTEM: Septic Tank New Existing •
Cesspool x New Existing O`
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0 /
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.)
ig.-:ture of Applicant
RECEIVED BY: ,' , - o�� - - -
R _,, 4 C -rk's O''fice
DATE: APR 29 199?
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