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044
JUDITH T. TERRYj Town Hall, 53095 Main Road
TOWN CLERK c ) P.O. Box 1179
REGISTRAR OF VITAL STATISTICS H :� Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
kVA, �.�.
�409 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. 1922-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BULLOCK, ARTHUR
Mailing Address 1 250 SMITH DRIVE NORTH
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 250 SMITH DRIVE NORTH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1351
Tax Map No. section 76.00 block 2 lot 19.000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
-6FFICE OF THE TOWN CLERK •c3IHU(
�'•
Town of Southold � CQG'_, Application No. / 9 L2.
Judith T. Terry, Town Clerk fg ��,
.x' <*) $10.00 Residential
Town Hall, 53095 Main Road a: -
p. 0. Box 1179 cf37�a�{ " ' �' $25.00 - Non-Residential
Southold, New York 11971 •
Telephone fid• )W
(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: AA 7'N ?_ ilcrG/c,
OWNER MAILING ADDRESS: 2_570 }?- ' D2 ,
c-"e Gil AL f/ ' /
OWNER PROPERTY ADDRESS: AL/
OWNER TELEPHONE NUMBER: ,_j' —
TAX MAP NO. : Section 7g Block Lot /
CROSS STREET: MA gfl7'/4-14-) .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing•
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,kld, le..--
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.)
gnature of Appli an
RECEIVED BY:
Town Clerk's Office
DATE:
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