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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ,� Southold, New York 11971
MARRIAGE OFFICER yQ ®�” Fax Fax (516) 765-1823
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(516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3103-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROCHARD, E. P., ESTATE OF
Mailing Address 1 C/O CHARLES CUDDY
Mailing Address 2 BOX 1547
City St Zip RIVERHEAD NY 11901-0000
Property Address 1 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-369-8200
Tax Map No. section 114.00 block 9 lot 14.001
Cross Street REEVE AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/24/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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v, OFFICE OF THE TOWN CLERK
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Town of Southold Q5 �C'D = - Application No. _v6_3
Judith T. Terry, Town "Clerk' - 4;2;..-f , � � 4/
Town Hall, ;�. -< $10.00 - Resi'dential
53095 Main Road ��.
P. 0. Box 1179 cn �-::.:- ' hzi ; $25.00 - Non-Residential
Southold, New York 119-71 - -' - /',,
Telephone .Q( $�
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(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.'-
Fee .$ C�
DATE ' Z�
Reiatfia
OWNER NAME: � �a, , C�,,
OWNER MAILING ADDRESS: ( 0 CAL ' - , ��.
A 0y l .. y 7 -
OWNER PROPERTY ADDRESS: 71460 1Qf
OWNER TELEPHONE NUMBER: �? ° — � co C7
TAX MAP NO. : Section / Block Lot l VI
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 4 Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
CIPP-
Cgna . e of App icant
RECEIVED BY:
Town t lerk'sOffice
DATE:
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1,4,
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