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JUDITH T. TERRY a=..- s Town Hall, 53095 Main Road ,
TOWN CLERK : g f P.O. Box 1179
REGISTRAR OF VITAL STATISTICS , ' Southold, New York 11971
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MARRIAGE OFFICER eta �� 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. 1803-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STORMS, GEORGE M.
Mailing Address 1 BRIDGE LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address I BRIDGE LANE
Property Address 2 NASSAU POINT
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7068
Tax Map No. section 118.00 block 3 lot 3.005
Cross Street NASSAU POINT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFt °CE •OF THE TOWN CLERK ' �FFO/A-
Town of Southold �O� CQ � Application No.' 0
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road h -� $10.00 - Residential
P. O. Box 1179 cn �j ;' $25.00 - Non-Residential
Southold, New York 11971
Telephone,( Y►�� '�/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ /0A -
DATE ///(9/b/
OWNER NAME:
OWNER MAILING ADDRESS: BRIDGE UWE:RIASSAUPOINT
CUTCHOCUC,PdY 1198G
OWNER PROPERTY ADDRESS
OWNER TELEPHONE NUMBER: , 719,-7c48
TAX MAP NO. : Section , 1/2 Block 3 Lot 3,4"
CROSS STREET: 445'9# v 44407- # JA
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New . Existi g X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /OA/ /
LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and 'closest road.) _
ignatu e,of Applicant
RECEIVED BY: .
Town Clerk's Office
DATE:
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a - MAP .,�1F : ,
t • PART OF LOTS /27 8 /28,
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NOTES „ 1y84
'# ®=MON. FND. - • . . NOV. 6, Job N-84-670
o=P/PE FND. 1000-118.03-02 Scale: l"=30' '
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