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JUDITH T. TERRY ' Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 1 L- r �� Southold, New York 11971
MARRIAGE OFFICER .�! Fax (516) 765-1823
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�! Telephone (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. 3172-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BUFKINS, JOHN AND DEBRA
Mailing Address 1 43100 NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 43100 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-6144
Tax Map No. section 59.00 block 4 lot 1 .000
Cross Street TUCKERS LANE
Issue Date: 2/04/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •c0 FD
Town of Southold � �CQ Application No. ' /7)-
Judith T. Terry, Town Clerk " !►�! $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 . cn Wit, rt* $25.00 - Non-Residential
Southold, New York 11971 %JoO ��`
Telephone 'Q( ;t `�►�� ���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
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OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation ,Permit No..
Fee $ MC-r-
-1
&) - /99
DATE i frig
OWNER NAME: l'OAIA_ him &) vL S
OWNER MAILING ADDRESS: �p� Pard Rd
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 57 ' 76c- CI Y y
TAX MAP NO. : Section 05-1„ f6i) Block ®90426) Lot C2ij/. 00 a 1' oo a , oaz
CROSS STREET: 1UUk-C45 1-490* 7/49 t04-
TYPE OF SYSTEM: Septic Tank New_ Existing
Cesspool ,r-New_ Existing 1/1
Residential Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to bes:id!og and close:t roads)
Sig► ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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