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JUDITH T. TERRY zTown Hall, 53095 Main Road
TOWN CLERK p eZfl P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
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�� Fax (516) 765-1823
MARRIAGE OFFICER ®� r,y®� 14.° °� 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. 3098-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHOLL, FRANKLIN A., JR.
Mailing Address 1 1340 BUNGALOW LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1350 BUNGALOW LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8243
Tax Map No. section 123.00 block 2 lot 17.002
Cross Street CEMTER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COFQ
Town of Southold - Y; CQG' Application No.--
Judith T. Terry, Town Clerk `ti $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 u' � _ $25.00 - Non-Residential
Southold, New York 11971 O .j
Telephone ( Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 8 t \k'CI 3
OWNER NAME: if\ \\\/\,, ���
OWNER MAILING ADDRESS: V
OWNER PROPERTY ADDRESS: ' P!)-24.0%...3 L
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OWNER TELEPHONE NUMBER: -2.C1,9) -- 2�3
TAX MAP NO. : Section l -23 Block 2- Lot \'') e
CROSS STREET: f- 51/4K-,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New { Existing 1-
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: Or' v own
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.)
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SignatuL24I(
. Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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SURVEY OF
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PROPERTY
CENTEAT MATTITUCK
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roFoFOLK COUNTY, N. Y.
w - 123' - 02 - 17.2N/O/F WILLIAM P. SCHOLL Jr• Scale 1" = 30
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Title Association. MA/K`°RO4D
11 SOUTHOLD, N.Y. 11971
90 - 190