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® Town Hall, 53095 Main Road
` P.O. Box 1179
~��®� � �� Southold, New York 11971
JUDITH T.TERRY ��„_. �r�%''1�!1 FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1369-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OLSEN, JAMES E.
Mailing Address 1 2420 BRAY AVENUE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 2420 BRAY AVENUE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 126.00 block 10 lot 3.000
Cross Street SECOND STREET
Date Of Last Pump Out 0/00/00
Issue Date: 1/22/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE'4 OF THE TOWN CLERK .c3VFFD(,r��'
Town of Southold � :.� C��" Application No. /361
Judith T. Terry, Town Clerk � :�
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 Ir3 70-0
$25.00 - Non-Residential
Southold, New York 11971 O :'QsTelephone
(516)
(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: ���� eS _ ��S' 7L/ •
OWNER MAILING ADDRESS: a 0 at-e-
) /I i- q,r
OWNER PROPERTY ADDRESS: 2I/t) 84 I9 y ljv.Pyj �-P
L.19 ( AE_ //7fq
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / e-6Block /O Lot
CROSS STREET: 0.., 14-'(S74-dee ?-
TYPE OF SYSTEM: Septic Tank New Existing (V'
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 12'
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.)
ignature o App icant
RECEIVED BY: ,�����
wnn Clerk's Office
DATE: /(17 (f
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