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,74P ,,`t Ask"' r� rt Town Hall, 53095 Main Road
144 P10. Box 1 179
• � , "u a Southold, New York 11971`''� @'"- tom:. r,i;
JUDITH T.TERRY ` F `� TELEPHONE
ro�rr CLERK ��<-7 (516) 765-1801
REGISTRAR 01 VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF-SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TAN.(( or CESSPOOL
Operation Permit No. 906-R Residential X Non-Residential
Fee $ ' 10.00 Septic Cesspool X
New Existing X
Name Of Owner WELLS, WEBSTER
Mailing Address 1 23 VASSAR PLACE
Mailing Address 2
City St Zip ROCKVILLE CENTRE NY 11570-0000
Property Address 1 1470 PARK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-766-0310
Tax Map No. section 12 '.00 block 8 lot 3.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/86
• ' •
Issue Date: 11/01/88 /Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERKc.\\V Fair
Town 'of Southold , �� t; . z," . Application No.
Judith T. Terry, Town Clerk . ;4` H 1sr
Town Hall, 53095 Main Road ° Residential
P. O. Box 1179 G Vttt 5$ Non-Residential
Southold, New York 11971 0` 0
Telephone ( .'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ %Q --
DATE (!:::.&\c, Zg.) 1`:Dc8 S
OWNER NAME: \/J2..\\
\/J \1s
OWNER MAILING ADDRESS: a,3 \llcsSpeR. V\o,c
S 7 O
OWNER PROPERTY ADDRESS: 1410 �aQ� hp; '(',T'c1c, Nl•Y. 11c‘5a
OWNER TELEPHONE NUMBER: 6-16 03ti0
TAX MAP NO. : Section a3 Block g Lot .3
CROSS STREET: IMflRzi\ sRA
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ,✓ New Existing V
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 'i \{a‘Jtirr►.(52,(2_,\c\86 oo\�
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.)
t `�� `
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••
Signature of Applica t
RECEIVED BY:
Town Clerk's Office
DATE: i-/DATE:
-/
4 KEYED /���I .:'E{F
E:J , _ 1986 I 1S8
Town Cleric Southold 'own Clerks Southold
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