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JUDITH T. TERRY ry Town Hall, 53095 Main Road
TOWN CLERK ® G1 P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER rte® O ���' Fax (516) 765-1823
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2002-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FRASER, DOUGALL & GERALDINE
Mailing Address 1 114 MOORINGS PARK DRIVE
Mailing Address 2 APT A502
City St Zip NAPLES FL 33942-0000
Property Address 1 7955 NASSAU POINT ROAD •
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6892
Tax Map No. section 118.00 block 4 lot 7.000
Cross Street TUTH I LL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• I III
OFFICE OF THE TOWN CLERK s��FF�(K�'- `
Town of Southold , 0�% . CQG' , Application No.,Z02„
Judith T. Terry, Town Clerk ' y
Town Hall, 53095 Main Road ; $10.00 - Residential
P. O. Box 1179 114 = z - )`' $25.00 - Non-Residential
Southold, New York 11971 O `� e
Telephone '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit, No.
Fee $ •
DATE / o 3/ / /
• OWNER NAME: ) 7e/a A•GL 'i-" ee a AL O 1 n r f"S �r1'
OWNER MAILING ADDRESS: //y fl a 1?/")'►S'J e4i?/( lke e. 4-39)- 19-1;?--
Net
9-JdZn/,t /L Es P 4-,4 3 3
OWNER PROPERTY ADDRESS: - L 4 ds/ta eat„,
ew� o ivy •iis— /
OWNER TELEPHONE NUMBER: f/3—. 6 /- A-171 -- 516 —�3v—Ges)9-?
TAX MAP NO. : Section / 1 ele Block 27/ Lot /
n r it ,/� '' JJ
-CROSS STREET:✓ �`�� � j � � �] ��/(� yLa.G
_ 0(-GLI d 0.'.c�K a.F.l Rd -
TYPE OF-SYSTEM: ptic Tank New Existing
Cesspool ✓ New Existing '`--
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: P//�/1/// o ,J �-rr•� / ,.» Ste-„ Aet 4.1
4 ►r i-, A Olt-.re44.
LOCATION MAP: Must be attached hereto before permit !nay be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, ' to building and closest road.)
92.1
Signature of Applicant
r
RECEIVED ,BY:
Town "; Dffice
DATE: Prov goo
Town Clerk SWUM