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JUDITH T. TERRY % Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Sd' �C �� Southold, New York 11971
(516) 765-1823
MARRIAGE OFFICER
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®,��® ®r��6 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. 1757-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RAPHAELSON, JAY
Mailing Address 1 BOX 633
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-8684
Tax Map No. section 31 .00 block 13 lot 9.001
Cross Street TRUMAN'S PATH
Date Of Last Pump Out 0/00/00
Issue Date: 9/18/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold �Q CQG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
$10.00 - Residential
P. O. Box 1179 <" �'
$25.00 - Non-Residential
Southold, New York 11971 0 .'"
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Telephone j .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / 7.5-7
Fee $ /U
DATE �i�/'/ ' /�P /99i
l
OWNER NAME: JA A-M/967.--,5-6
OWNER MAILING ADDRESS: J3o,,Y (Q_33 /lif/-/iv £,t
AM/7Jo Al J /V y' // y •
OWNER PROPERTY_ ADDRESS A-S. 4 6D U�
OWNER TELEPHONE NUMBER: 5/(e / 77•- (Q P7"
TAX MAP NO. : Section 3/ Block / 3 Lot 7, /
CROSS STREET: „„7J��E'11� h/,y yS EAcrotFTi2u A-iv r ,o4/7/
TYPE OF SYSTEM: Septic Tank X- - New Existing y
Cesspool y New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: klzi o? 7i i 17/
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 closestroad.)
ZZ
&gnat e o Applicant
RECEIVED BY: b.-e, - -
Tow ' Clerk's Office .
RECEIVED
DATE: •
SEP 181991
Town Clerk Clerk Soottiord -
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