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JUDITH T. TERRY ;. Town Hall, 53095 Main.Road
TOWN CLERK ;„ v T P.O. Box 1179
REGISTRAR OF VITAL STATISTICSC Southold, New York 11971
MARRIAGE OFFICER ®
t. /% Fax (516) 765-1823
'yol 1P, 0 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. 3025-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FULLER, H. ELLSWORTH
Mailing Address 1 CIO DENNIS P. FULLER.
Mailing Address 2 1300 YORK ROAD, SUITE 240
City St Zip LUTHERVILLE MD 21093-0000
Property Address 1 9280 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 410-296-4646
Tax Map No. section 118.00 block 6 lot 6.000
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/14/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3VFFO(,r
Town of Southold � _ CQ ' Application No. 30
Judith T. Terry, Town Clerk h :,
Town Hall, 53095 Main Road - . $10.00 - Residential
i 5 'i
P. O. Box 1179 v' V , _ i
$25.00 - Non-Residential
Southold, New York 11971 O � `° ' 0���`
Telephone 414-11411. �i
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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 $ /08 o®
DATE 66-09 3
OWNER NAME: 4,1
OWNER MAILING ADDRESS9 / fS f, j,tek
(3o0 kpk.k P,Gyarte, (k), v eRui1 lb
OWNER PROPERTY ADDRESS: x0 ,
OWNER TELEPHONE NUMBER:(JO) Lid G
TAX MAP NO. : Section t, 1 Block 0 Lot ‘;
CROSS STREET:
TYPE OF SYSTEM: '--,-Septic`-Tank- = --New Existing ��
Cesspool New Existing
Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ulf
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.)2,1,15.cry-64--deg.,
0r'
Signature of Applicant
RECEIVED BY: _ _ -.--.
Town 'Clerk's' Office
DATE:
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