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Vro ¢ko"r� L ✓ nHall,P.O.own Box 1179095 Main Road
�® s� Southold, New York 11971
.rrJUDITH T.TERRY ' ®1 ��10'� FAX(516)765-1823
TOWN CLERK
i#/l TELEPHONE(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. 1333-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WISSEMANN, JOHN AND NANCY
Mailing Address 1 BOX 524 _
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 PRIVATE ROAD - CEDAR BEACH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2266
Tax Map No. section 90.00 block 4 lot 11 .001
Cross Street CLEARVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 12/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
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OFFICE ,OF THE TOWN CLERK ���FFO
Town of Southold �� Application No. /33_7
Judith T. Terry, Town Clerks43.
Town Hall, 53095 Main Road :x .�� t Residential
P. O. Box 1179 ; Non-Residential
Southold, New York 11971 O - �0���
Telephone ( •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE „94-----c, o�
OWNER NAME: \kW/Ai oloiP 4i1vci /c5 ,v 4/4/
OWNER MAILING ADDRESS: 560PC (...E.-54
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OWNER PROPERTY ADDRESS: M//47 , &, J? c&-)4"4 ,Ref--4c#
.5'®cdr/teg-y, /11$
OWNER TELEPHONE NUMBER: 76r-2-2-46 ,
TAX MAP NO. : Section 9® Block , Lot `L I
CROSS STREET: c L 1.1,4.02.--c-t0_�/.
TYPE OF SYSTEM: Septic Tank ✓ New Existing ✓/
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,r/OV ?�
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.)
Signat re of Applicant
RECEIVED BY: , (_,U -
own Clerk's Office
DATE: /Z-/S/�y •
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