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/� Town Hall, 53095 Main Road
cam® O P.O. Box 1179
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$•." Southold, New York 11971
JUDITHTTERRY ,iFAX(516)765-1823
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TOWN CLERK TELEPHONE(516)765-1801
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. 1189-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
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Name Of Owner CULLATT, STEPHANIE
Mailing Address 1 1875 WICKHAM AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1695 WICKHAM AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8893
Tax Map No. section 140.00 block 1 lot 1 .000
Cross Street FREEMAN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN QLERK --,3\V
Town of Southold C'QG' - Application No. /1/1
Judith T. Terry, Town Clerk . � y:i
Town Hall, 53095 Main Road ,. } •
-� $10.00 - Residential ,/
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P. O. Box 1179 En : , i
�- ,_ •fir , $25.00 - Non-Residential
Southold, New York 11971 - . O ``® ' g�
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Telephone e 440•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: 3l' l-in i , 1. �v�� I G f
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OWNER MAILING ADDRESS: $�-j
��r 10,4 . (/19 ra-
- - - OWNER PROPERTY_ADDRF_SS: -I�o-)�
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OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section VAD
0 Block 1 Lot
CROSS STREET: D f(
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: U JLN)S)- V
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.)
SigiIttyre of Applicant
RECEIVED BY: "
Town Clerk's Office
DATE:
cop)„(-2,10haie) ;, r ca.-a (1
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