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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. 999-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BRUCE, FREDERIC J.
Mailing Address 1 4150 WUNNEWETA ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4150 WUNNEWETA ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6678
Tax Map No. section 111 .00 block 14 lot C.000
Cross Street LITTLE PECONIC ROAD
Date Of Last Pump Out 0/00/87
Issue bate: 2/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK g�\\FFQU,.'-
Town of Southold 0.� L_ CQG• Application No. 99?
Judith T. Terry, Town Clerky
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Town Hall 53095 Main Road . 7 Residential
P. 0. Box 1179 �' �£ ' � a'. ' ��' Non-Residential
Southold, New York 11971 OO
Telephone j 41
(516) 765-1801 •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /t2
DATE C16f, /91
fii-P6erc_ \J , l3/2C/CiOWNER NAME:
OWNER MAILING ADDRESS: '/t Ar✓/✓i% /x/77) rek
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: fit th-‘ 4 7
TAX MAP NO. : Section /1/ Block 1//' Lot
CROSS STREET: ,/Trie /fp
TYPE OF SYSTEM: Septic Tank V New Existing V
Cesspool 1/ New Existing
Residential J Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1'90
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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