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• t�, ��� Town Hall, 53095 Main Road
��� P.O. Box 1179
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�—`_ �� ° Southold, New York 11971
JUDITH T. TERRY "z#/i/i°��II TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1060-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VAIL, FLOYD R. AND AUDREY R.
Mailing Address 1 685 BUNGALOW LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 685 BUNGALOW LANE
Property Address 2
City St Zip MATTTITUCK NY 11952-0000
Owner Telephone No. 516-298-8787
Tax Map No. section 123.00 block 3 lot 9.000
Cross Street CENTER STREET
Date Of Last Pump Out 0/00/69
Issue Date: 3/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
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Town of Southold LG- Application No./Oc 2
Judith T. Terry, Town Clerk ` yon. ; tiF
Town Hall, 53095 Main Road ` A :V,r�«r ,,. .rte) Residential
P. O. Box 1179 , Non-Residential
Southold, New York 11971
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Telephone .Q( •
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O. —
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DATE .3/07
OWNER NAME: C-40 f/3 / ' 0,/ 4 vdrey %,/
OWNER MAILING ADDRESS: 675- ej/vv'C�docd 1;9>v'e
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0r�frcl cI(4/1.
OWNER PROPERTY. ADDRESS: S-4,4E-
OWNER TELEPHONE NUMBER: r 7g7
TAX MAP NO. : Section /23 Block 3 Lot 9`
CROSS STREET: Cendev Sireef
TYPE OF SYSTEM: Septic Tank /'- V New • Existing V
Cesspool New Existing V'
Residential 1,7 Non-Residential
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DATE OF PREVIOUS PUMP-OUT: fiproA- /99
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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Sig 4Sature of Applicant
RECEIVED BY:
.. ° Mi'� '9 own erk's • Tfice
DATE:
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