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JUDITH T. TERRY ... ; : Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICScr2 Southold, New York 11971
MARRIAGE OFFICER yQ O�. Fax (516) 765-1823
jig �� �� Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3174-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WILSBERG, E. PAUL
Mailing Address 1 P. O. BOX 1429
Mailing Address 2
City St. Zip MATTITUCK NY 11952-0000
Property Address 1 4095 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4409
Tax Map No. section 122.00 block 5 lot 23.005
Cross Street NEW SUFFOLK AVENUE
Issue Date: 2/04/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
' OFFICE OF THE TOWN CLERK 'COFD(e /
Town of Southold �� Chi Application No. .3/'`f
Judith T. Terry, Town Clerk ,Oh;
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 to =' $25.00 - Non-Residential
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Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
'IP LI
- _ _ for - --
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. l 12 -5-- 23.5-
Fee
3.EFee $ 1c0_0 II
DATE 2 1 q4
OWNER NAME: T. 4'PUL Wit-Sae- 12G
OWNER MAILING ADDRESS: 0 60 x i'I 2.9
)fl 4-7-r i r c-'c, & .Y. i i 9 - 2-
OWNER- PROPERTY
-
OWNER--PROPERTY ADDRESS: _4095- O4:.Qf- v c I.-
AAA:-OWNER TELEPHONE NUMBER: 5I(0-,2q21- */ 4109
TAX MAP NO. : Section Block Lot
CROSS STREET: )j 6.) up r-o L is IWe
TYPE OF SYSTEM: Septic Tank V" New Existing '✓
Cesspool New Existing
Residential V Non-Residential
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 o Applicant
RECEIVED BY:
Town Clerk's Office
RECEIVED
DATE:
FEB 3 1994
Southold Town Clerk
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