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' EFTI Town Hall, 53095 Main Road
&ft � 'X` P.O. Box 1179
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Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1412-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GREMLER, WILLIAM M.
Mailing Address 1 P. O. BOX 859
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 375 KRAUS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9379
Tax Map No. section 122.00 block 5 lot 6.000
Cross Street OLE JULE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/13/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • .
c\SFFOUrp• //
:ti own of Southold D = Application No.P71/
7`/
JWdith T. Terry, Town Clerk •
Town Hall, 53095 Main Road l{ ... $10.00 - Residential
P. O. Box 1179 u' $25.00 - Non-Residential
Southold, New York 11971 O ® �`
Telephone _0j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
For
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /"//A-Cit / )i, /5/0
•
OWNER NAME: &,LL,4-,zi /I, %EptLg'g_
OWNER MAILING ADDRESS: P .®. 17®x e.i-j•
A.) 5_z—
OWNER PROPERTY ADDRESS: ft/�vS /Cb
fl 77 17 '( f /d, �,
• OWNER TELEPHONE NUMBER: 141"- 93 7
TAX MAP NO. : Section /LZ Block . Lot
CROSS STREET: OLEcicl LE L4 •
TYPE OF SYSTEM: . Septic Tank New Existing
Cesspool New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 1-7/ ,/ /1,
/
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.)
Signature of Applicant
RECEIVED BY: (1//a ani «J
TownClerk's Office
RECEIVED
DATE:
1111\R
Town Clerk Southold
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