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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK . gZnJ sr .Y % P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
� js". • 1!4 i Southold, New York 11971
MARRIAGE OFFICER c ,�_ � 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. 1820-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner GRAUER, JOHN K. AND MARY K.
Mailing Address 1 P. O. BOX 217
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 2100 ALDRICH LANE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4137
Tax Map No. section 125.00 block 1 lot 2.020
Cross Street FRANKLINVILLE ROAD
ti' Date Of Last Pump Out 0/00/00
Issue Date: 12/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK SVFFO(,'•'• ����
Town of Southold �� CQ ' Application No.
Judith T. Terry, Town Clerk, '' t ���
Town Hall, 53095 Main Road { - $10.00 - Residential
P. O. Box 1179 -(13- LK` , tri; $25.00 - Non-Residential
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Southold, New York 11971 .y
Telephone _ 1 It
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE lal � ��
OWNER NAME: „l a f-(ik.) C jkAt,tr y�l
OWNER MAILING ADDRESS: POG1C
f 4''C 2.cz
OWNER PROPERTY ADDRESS: gN,, /00 ,4LDAJ C14 L.4
4v-,12&-e..- //idr ` 9 , 7
OWNER TELEPHONE NUMBER: 5/6 9 t (7/ 3
TAX MAP NO. : Section f Block / Lot
CROSS STREET: / // 7E •
TYPE 'OF SYSTEM: Septic Tank i.7 New L, Existing
Cesspool tt/ New Ps Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: IYO1
LOCATION MAP: Must be attached hereto before permit maybe 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
RECEIVED BY:
Town Clerk's Office
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