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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK ® Fri
` P.O. Box 1179
.�� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ��� Fax (516) 765-1823
_
MARRIAGE OFFICER ®� ���
RECORDS MANAGEMENT OFFICER -_s_t4 Telephone (516) 765-1801.�
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. 3258-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CUBBON, ROBERT J.
Mailing Address 1 P. O. BOX 1283
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1900 PARK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8860
Tax Map No. section 123.00 block 8 lot 6.000
Cross Street MARRATOOKA ROAD
Issue Date: 10/06/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,'
OFFICE OF THE TOWN CLERK•
so
OFFICE '•CQG
Town of Southold % � Application No. 3025_
Judith T. Terry, Town Clerk J �'„ n y
Town Hall, 53095 Main Road :G $10.00 - Residential r/
p. 0. Box 1179 to - ;) $25.00 - Non-Residential
Southold, New York 11971 ® ' 0"�`�
Telephone,( 1, •1
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 5e.,"---Pr (177 /99
•
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OWNER NAME: � vel% a/. 1���,/�®,oe�
OWNER MAILING ADDRESS: Pc2, OcX
4 777(7.--Ciefc" % Y // 93;2
OWNER PROPERTY ADDRESS: - /90'0 69-47(
/17,977/i c'c, l!l Y, l/9�Q
OWNER TELEPHONE NUMBER: c2ri ROP6C,
TAX MAP NO. : Section j(o� 3 Block Lot
CROSS STREET: /9 ff'//-7Q ,4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool JC New Existing )0
Residential XC 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.)
Sig( .ture of Applicant
RECEIVED BY: Cel
TownClf � lerk's Office -
DATE: /0 - 5--
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