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* i Town Hall, 53095 Main Road
cf,if' W ` P.O. Box 1179
=y® ® �® �/ Southold, New York 11971
JUDITH T.TERRY .!C i���' TELEPHONE
TOWN CLERK ''".via04 (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. 761-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X '
New Existing X
Name Of Owner SCHEERS, ORA MARTIN
Mailing Address 1 BAY AVENUE, BOX 102B
Mailing Address 2
City St Zip CUTHCOGUE NY 11935-0000
Property Address 1 BAY AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6968
Tax Map No. section 138. 00 block 2 lot 7.000
Cross Street PINE TREE ROAD
Date Of Last Pump Out 5/14/82
Issue Date: 7/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c,�FFO(,�C=
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