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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK = ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ° so'� Fax (516) 765-1823
! Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1855-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STALZER, ANNA
Mailing Address 1 P. O. BOX 31
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 6190 PECONIC BAY BLVD.
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-8408
Tax Map No. section 128.00 block 2 lot 5.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/84
Issue Date: 3/16/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c3IF�(,-
Town of Southold �� t2 . Application No. 78- c5�
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 Lni $25.00 - Non-Residential
Southold, New York 11971
Telephone ®.( NitN°'°•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ •
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DATE Jd / y
OWNER NAME: /A >i /A „S -n9 1_ 2 %
OWNER MAILING ADDRESS: 1 /' 31))/ 3 /
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OWNER PROPERTY ADDRESS: -64 G_ J��C:6""%r/iG / /7 y �Z-1/
OWNER TELEPHONE NUMBER: ...4-91? - �-90 e
TAX MAP NO. : Section / 2- 8- Block v Lot
CROSS STREET: / t7 ✓t
TYPE OF SYSTEM: Septic Tank New Existing t
Cesspool r/ New Existing
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Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / '7j / -
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 Ap icant
RECEIVED BY:
taidi ,itttltlCCerk's Office
•
DATE:
11���
MAR 1619V
Town Clerk Southold
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