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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
�� Fax (516) 765-1823
MARRIAGE OFFICER s O ®� •
----IW� $V � Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3148-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WRIGHT, JOHN F. AND CAROLYN F.
Mailing Address 1 P. O. BOX 979
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2715 BRAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8536
Tax Map No. section 126.00 block 9 lot 12.000
Cross Street PECONIC BAY BLVD.
• Date Of Last Pump Out 0/00/00
Issue Date: 11/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK c0F14� a
Town of Southold �� ;: CQG' Application No�J 9
Judith T. Terry, Town Clerk . � ' v y�',
$10.00 - Residential
Town Hall, 53095 Main Road .�
P. O. Box 1179 u' ' T► : $25.00 - Non-Residential
Southold, New York 11971
Telephone �( NO I.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: 'O , ��r �_ �� 1i\K
OWNER MAILING ADDRESS: ,\`c•—\Q\
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 9\%, S 3
TAX MAP NO. : Section ` `Q-A Block C\, Lot
- CROSS STREET: Vs ®\-k--N\ �jts,
TYPE- OF SYSTEM: --Septic- Tank New Existing
Cesspool x New Existing
Residential )( Non-Residential
DATE OF PREVIOUS PUMP-OUT:_ \K `1 � °— \•c'S
-\\ \DW`I.Nr ,
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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411167. \
ignature o App scant
RECEIVED BY •
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DATE: • NOV W5
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