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JUDITH T. TERRY , Town Hall, 53095 Main Road
TOWN CLERK � P. O. Box 1179
11:REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER a� Fax (516) 765-1823
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. 1643-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GRAESER, RONALD AND SHEREE
Mailing Address 1 DICKERSON, LOU JEAN
Mailing Address 2 BOX 542
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 NEW SUFFOLK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5184-
Tax
16-734-5184Tax Map No. section 109.00 block 6 lot 3.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
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Issue Date: 3/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OF1FICE OF THE TOWN CLERK IcgFi(,���= /r
Town of Southold � _ CQ Application No
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road `="`�"''_ -Sig) $10.00 - Residential
P. O. Box 1179 Lnj=^� $25.00 - Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 16.7 ,41-.
Fee $
DATE 3
OWNER NAME: _ \\ re-e-C-ca_ese-C „Lou „Sea-y\ ec-S D1\1
OWNER MAILING ADDRESS: "t S 4
OWNER PROPERTY ADDRESS: :e.;.., S ` Act_
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CAL) 6c)d 1
OWNER TELEPHONE NUMBER: Shp - 7 3(8
TAX MAP NO. : Section /o g Block 62 Lot
______S
CROSS STREET: 'R`,0p a•s-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool G-- New Existing
Residential .i--' Non-Residential
DATE OF PREVIOUS PUMP-OUT: / C •
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 Applicant
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RECEIVED BY: AL/ G
Town Clerk's Offi e
DATE: — / ®' 97
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