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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p -Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER 411A,
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MARRIAGE a1� i�� 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. 2092-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BUMBLE, CHARLES JR.
Mailing Address 1 14 SOUND ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 14 SOUND ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0564
Tax Map No. section 35.00 block 1 lot 19.000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/88
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •cSFD(,(- --
Town of Southold �� x. CQG Application
Judith T. Terry, Town Clerk ef-2 `?
Town Hall, 53095 Main Road w r
$10.00 - Residential
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P. O. Box 1179 cry2 ;�' ` $25.00 - Non-Residential
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Southold, New York 11971 O
Telephone */*--- O �i
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. A6)9 -=---
Fee $/6 —
DATE
OWNER NAME: CiQleS [p/#,62
OWNER MAILING ADDRESS: c /z/,h C,6
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OWNER PROPERTY ADDRESS: , pj(�Ji °J (�
9r1 art iU, c f/�'
OWNER TELEPHONE NUMBER: e(77 c.9 6-6"
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TAX MAP NO. : Section 3,1; •- : ock f Lot I
CROSS STREET: f tf
TYPE OF-SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential /x 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.)
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Signature . : .plicant
RECEIVED BY: J
Town Clerk's Office
DATE: -1//37/
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