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Town Hall, 53095 Main Road
=e?� 4i' P.O. Box 1179
iN% Southold, New York 11971
JUDITH T.TERRY 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. 1154-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WURTZ, WILLIAM AND JUDITH
Mailing Address 1 2725 BAY AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2725 BAY AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7328
Tax Map No. section 97.00 block 4 lot 14.000
Cross Street LESLIE'S ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c31 //( 5-Y
Town of Southold �� CD ' , Application No.
Judith T. Terry, Town Clerk # K ~
Town Hall, 53095 Main Roadc=1 . .:= gc 7 $10.00 - Residential (/ .
u
P. O. Box 1179 ' µr. .` $25.00 - Non-Residential
Southold, New York 11971 O
- .a0 �•
Telephone alAlit
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ PP _.
DATE C.o j/ r7
OWNER NAME: A0/9114- -LI,),/t�
OWNER MAILING ADDRESS: 7 Z-j , Xj "
/Wili)J--
OWNER -PRORERTY ADDRESS: c_fr/#X2
• OWNER TELEPHONE NUMBER: 734(— 7 ? 2J•
TAX MAP NO. : Section (n7_ QTJ Block rD 1 , 6t) Lot Q lq, ®Q
CROSS STREET: /F5LIE/3 ,SOA
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New (V Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4()//F 04g-u7
LOCATION MAP: Must be attached hereto before permit_may be issued. _ _
(Locate building and system; give north arrow and feet
.— — of distance, apprpx„linatel_y_,_ to bu ldinal and_ closest road.).17
-
Srmn; ur'` of! pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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