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JUDITH T.TERRY t ♦� Town Hall,53095 Main Road
TOWN CLERK t g $ P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS ` O , Southold,New York 11971
MARRIAGE OFFICER 'S \`' �g� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER ®1 ED I," Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3298-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BUSCH, STEVEN AND LOUISE
Mailing Address 1 9060 PECONIC BAY BLVD.
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 9060 PECONIC BAY BLVD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5338
Tax Map No. section 126.00 block 5 lot 9.000
Cross Street BRAY AVENUE
Issue Date: 12/28/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFr;.riE OF THE TOWN CLERK cOO! "-
•� Town of Southold Application No3a 9f/
Judith T. Terry, Town Clerk : y►
Town Hall, 53095 Main Road 1 $10.00 - Residential -�
P. O. Box 1179 GJI . *� �' $25.00 - Non-Residential
Southold, New York 11971
0
Telephone _ .( alk
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ fib • 0
i
DATE Z VZ319.)I
OWNER NAME: T1'``1�(.� US�N LOU S 11-e->>thkLS'E usa-F
OWNER MAILING ADDRESS: Ci filo d V�C...®iJ
- -- - OWNER PROPERTY ADDRESS: _ _ -
OWNER TELEPHONE NUMBER: — ` -9 g - 573-
• TAX MAP NO. : Section ( Block Lot 9
CROSS STREET:•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X, _ New Existing
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 building and closest road.)
1Q
Signature of Applicant
RECEIVED BY:
,1.01;-` ai,.-r-k's Off ce .
DATE: DEC ? � 1994 - - - - -
town aerh Southold ,