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JUDITH T. TERRY4 Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS '7"-V>
in Southold, New York 11971
MARRIAGE OFFICER "- ®�
Fax (516) 765-1823
,�®� Aik Or, 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. 3117-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STERN, ARNOLD
Mailing Address 1 1134 GARDEN STREET
Mailing Address 2
City St Zip HOBOKEN NJ 07230-0000
Property Address 1 4415 CAMP MINEOLA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 201-653-3213
Tax Map No. section 123.00 block 5 lot 22.000
Cross Street KRAUS ROAD
Date Of Last Pump Out 0/00/87
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
S IIS
OFFICE OF THE TOWN CLERK COMA'
Town of Southold CQ ' Application No.YLL
Judith T. Terry, Town Clerk ;' t k.
Town Hall, 53095 Main Road = $10.00 - Residential
P. 0. Box 1179 u' `. --" ` $25.00 - Non-Residential
Southold, New York 11971 O ��`
Telephone 40.( 01
(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: AIRN
OWNER MAILING ADDRESS: )13V GAO as/ c' Qo
•„,r`01 . �l�! D 7 0
OWNER PROPERTY ADDRESS:
k.V- /19c
OWNER TELEPHONE NUMBER: f L 5 3 . D43
TAX MAP NO. : Section Block 5 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing zCesspool '_ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 63 7
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 .-nd closest road.) —
111118111INA
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•
Signature of Ap*Iicant
Y - •
RECEIVED BY: - -
Town Clerk's Office
DATE:
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