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Town Hall, 53095 Main Road
�, P.O. Box 1179
s- Southold, New York 11971
JUDITH T.TERRY r ',top'',''Pero' TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF 1-, 1E TOWN CLERK
TOWN Okh SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 884-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FEINBERG, RANDALL J.
Mailing Address 1 P. O. BOX 186
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 COX NECK ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9328
Tax Map No. section 113.00 block 14 lot 9.000
Cross Street ROUTE 48/SOUND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/14/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cl\VFDi',,�,:=
Town of Southold �) ,,,i*.--; Application No.
Judith T. Terry, Town Clerk ���4.$4,' y
Town Hall, 53095 Main Road .: -4614,A4 ..A 7 Residential
P. O. Box 1179 .. ri- 1- 'moi�.% Non-Residential
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Southold, New York 11971 ‘P',e*, 0���`
Telephone -...(11 4 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
-
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ IIif) •OO
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OWNER NAME: 1 CC Na
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OWNER MAILING ADDRESS: � 0 Qx 1 g
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OWNER PROPERTY ADDRESS: C cX /J �C Z. Rc c,,cn -
OWNER TELEPHONE NUMBER: cit, - q 9 c? - 3
TAX MAP NO. : Section 11 3 Block ) Lf Lot 9
CROSS STREET: ( , ,+ Q_. t-(. _ S 0 uLj3c1 -A 642. -
TYPE OF SYSTEM: Septic Tank \/ New Existing L---"
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: NOt.3 -Q-
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 of Applican
RECEIVED BY:
Town Clerk's Office
DATE:
) 066
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