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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK z; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
� Fax (516) 765-1823
MARRIAGE OFFICER
i' 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. 1769-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OSLER, WILBUR F.
Mailing Address 1 3 PASTURE ROAD
Mailing Address 2
City St Zip WHITEHOUSE STATION NJ 08889-0000
Property Address 1 PECONIC BAY BLVD.
Property Address 2 (HOUSE #1 )
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 908-236-2398
Tax Map No. section 126.00 block 11 lot 17.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/86
Issue Date: 9/26/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c��FFO(,r" ' '" /70
Town of Southold �� CQG'_ Application No.
Judith T. Terry, Town Clerk '. ..
V..,,,,- $ .
Town Hall, 53095 Main Road 8' „,,r .,, `.i..;, , $10.00 - Residential
P. O. Box 1179 v' v *' ,= ;,' .WS: $2 .00— Non-Residential
Southold, New York 11971 Or 4orse� - .
Telephone _61 Y► ,• . ' _ •s }_;,,
(516) 765-1801 ; ,
. TOWN OF SOUTHOLD r ' '
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for :,;:.
OPERATION PERMIT
SEPTIC TANK or CESSPOOL 1' ,
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Operation Permit No. .
p•�a
Fee $ 1 `+'''
DATE q• 12:5. qI
OWNER NAME:
VU.2-.)U--IL. \--":1- 0S-Lf&.--) . ' ,.-
OWNER MAILING ADDRESS: 3 4 - CLLLt, e.o.A.4 - .-
nt\r,A .�g vvott,s.E. 57461 I I M
OWNER PROPERTY ADDRESS: P4- t—SLZ, Ii:Z,44 0 _.
N1/4 A:Tr-n.7 u,O.A.., k9 Qi.
OWNER. TELEPHONE NUMBER: (90q)_(Z36.2-6q2, 'I' (5, ltich 2q4' • g6T5---
TAX MAP NO. : Section l `Z cP Block k l' Lot ,l .
CROSS STREET: \3QA. A\r-t ,,
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TYPE OF SYSTEM: Septic Tank New Existing
” 5. Cesspool New Existing '-
Residential ) . Non-Residential •
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DATE OF PREVIOUS PUMP-OUT: " � ye..4,itz44D1'
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.)
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RECEIVED BY.
Town Clerk's Office ;;
DATE:
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