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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax, Fax (516) 765-1823%
MARRIAGE OFFICER ��,e• Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 1 * Ill
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3255-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GRATHWOHL, RICHARD
Mailing Address 1 25975 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 25975 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-7311-6501
Tax Map No. section 109.00 block 2 lot 9.000
Cross Street ALVAH'S LANE
Issue Date: 10/06/911 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE`-OF `THE TOWN CLERK cl\VFO(,(-
� QG= Application No.
Town of Southold Q C 3 �5 S
Judith T. Terry, Town Clerk _ ' y:�
Town Hall, 53095 Main Road a -� $10.00 - Residential
P. O. Box 1179 to ; $25.00 - Non-Residential
Southold, New York 11971 O 0*.$
Telephone 0.( y►
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 9-- C"j" V
OWNER NAME: lt,C.1"—\[LAI) V, G T*00 \A-C---
OWNER
kt_—OWNER MAILING ADDRESS: MI— AP— I4AIIVUA O
°tor77-1 (rU6 1 y
OWNER PROPERTY ADDRESS: d?
OWNER TELEPHONE NUMBER: 7:W —C,,S1D -
TAX MAP NO. : Section /0 7 Block ZL Lot 9
CROSS STREET: j\� 14 IS L
TYPE OF SYSTEM: Septic Tank New Existing ,le"
Irl
Cesspool v/ Existing It
Residential ✓ Non-Residential
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.)
it, _✓
Signature of Applicant
RECEIVED BY: ((:).707 \-, �(7 -I-DsR
Town Clerk's Office
DATE:
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