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Town Hall, 53095 Main Road
' �i�� P.O. Box 1179
_� ®��• Southold, New York 11971
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JUDITH T.TERRY =®`� �Ls' �i��t� TELEPHONE
TOWN CLERK (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. 891-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WAGNER, ANDREAS
Mailing Address 1 BOX 29
Mailing Address 2 STARS ROAD
City St Zip EAST MARION NY 11939-0000
Property Address 1 STARS ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1563
Tax Map No. section 22.00 block 2 lot 17.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/83
Issue Date: 11/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COMA'
Town of Southold CQG Application No. • D elJ
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road ,.: -� 7 Residential
P. O. Box. 1179 u' =' k r,.r._ 'moi `' Non-Residential
Southold, New York 11971 O O� '`
Telephone _*! ��;
(516) 765-1801
TOWN OF SOUTHOLD •
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEOVE
APPLICATION OCT 1 9 1988
for
SWOON TOT'dl Clerk
OPERATION PERMIT
SEPTIC TANK or CESSPOOL - ,
Operation Permit No.
Fee $
DATE Or / /J
OWNER NAME: ��2>�%�4-o/)
OWNER MAILING ADDRESS: _5-2%/'”j Id j( e) ?r d
ir•-7.;'511 4/-7.
OWNER PROPERTY 'ADDRESS: S L l //
OWNER TELEPHONE NUMBER: 477
TAX MAP NO. : Section g Block Lot /7
CROSS STREET: .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing '
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 5----)1#: P /37f / ?F3
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.)
Signature of Ap icant
RECEIVED BY:
Town Clerk's Office
DATE:
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