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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK O .2G
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER0 0� Fax (516) 765-1823
�yol 11D��l•� Fax
(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. 2031-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FISK, CARL
Mailing Address 1 2010 NORTH BAYVIEW ROAD EXT.
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2010 NORTH BAYVIEW ROAD EXT.
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1348
Tax Map No. section 79.00 block 6 lot 3.006
Cross Street JACOBS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 12/29/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FOC,- 3
Town of Southold �� . CQG_ Application No.
Judith T. Terry, Town Clerk •
Town Hall, 53095 Main Road �:?s $10.00 - Residential
p. O. Box 1179 tri bsi ; $25.00 - Non-Residential
Southold, New York 11971 O ® ' •�`
Telephone =(
14- 0;91
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
,Operation Permit No.
Fee $ •
DATE 72- 2-3) /9p-
OWNER NAME: C/
OWNER MAILING ADDRESS: ZO/2 X... ,5A m- AP_ '7
v7/- y • %/ 7/
OWNER PROPERTY ADDRESS: ..374 ,W.-
OWNER TELEPHONE NUMBER: 7 /'c.? /4K
TAX MAP NO. : Section 4/ 73rff y Block 7 -th71,‘ Lot
-
" ' :-CROSS STREET: JAC° '3s I/9 A//
TYPE OF ,SYSTEM: " Septic Tank - New Existing
Cesspool L .- New Existing
Residential j - 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
REC_ EIV;ED BY:
Town Clerk's Office "
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