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Cr) Town Hall, 53095 Main Road
P.O. Box 1179
#, ' Southold, New York 11971
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JUDITH T.TERRY „�i�i���� FAX(516)765-1823
TOWN CLERK 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. 1513-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WOLBERT, AUDREY A.
Mailing Address 1 4820 NEW SUFFOLK LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4820 NEW SUFFOLK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6983
Tax Map No. section 110.00 block 8 lot 15.000
Cross Street WICKS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/06/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .\ FOL4
4rown of Southold Application No. /573
Judith T. Terry, Town Clerk 'a � ►:� P/
Town Hall, 53095 Main Road
$10.00 - Residential
to e� `=`' ' • $25.00 - Non-Residential
P. O. Box 117 9 ,,,�,� ,�, �i �
Southold, New York 11971 0� � ~`'M?." 0���`�
Telephone OjAld
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
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Operation Permit No.
Fee $10.00
DATE 01/August 1990
OWNER NAME: AUDREY A. WOLBERT •
OWNER MAILING ADDRESS: 4820 New SuffolkLane
Cutchogue New York 11935
OWNER PROPERTY ADDRESS: 4820 New Suffolk Ln. Cutchogue NY.11935
OWNER TELEPHONE NUMBER: (516) 734®6983
TAX MAP NO. : Section 110 Block 8 Lot 15
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: NIA
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 ture of Applicant
RECEIVED BY:
TowREE IS Office
DATE: QIJG O's 1990
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Audrey A. VJolbert
4820 New Suffolk Ln.
Cutchogue --NY. 11935 <
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