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Town Hall, 53095 Main Road
® 0. � i`� P.O. Box 1179
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2 tz �U," , Southold, New York 11971
® i14 FAX(516)765-1823
JUDITH T.TERRY '= z/ � TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 960-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner ABBOTT, JOHN J.
Mailing Address 1 147 CARLTON TERRACE
Mailing Address 2
City St Zip STEWART MANOR NY 11530-0000
Property Address 1 8630 PECONIC BAY BLVD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4882
Tax Map No. section 126.00 block 5 lot 1 .000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 12/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �C.OFO�l. ,
Town of Southold % • -iCQ Application No. 7 9 Ct.G
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road :4 Residential
P. O. Box 1179 cn .3., Non-Residential
Southold, New York 11971 O ® "
Telephone : .( .'
(516) . 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 2 t ,
OWNER NAME: AAA 0 , A4/0
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OWNER MAILING ADDRESS: /q7 (4f1L 77,() 7-4-72A m-c/g.
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OWNER PROPERTY ADDRESS: 26 30 f cc4fc / C � n/1—
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OWNER TELEPHONE NUMBER: ng'" 4/9r2-'
TAX MAP NO. : Section Block /-77,- c25 Lot po
CROSS STREET: j 'rc v 4-t'/ -
TYPE OF SYSTEM: Septic Tank X, New x Existing
Cesspool New Existing
Residential 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.)
C 1
Sig•li to e or Applicant
RECEIVED BY: •
own Clerk's Office
DATE: / -1-/ ( (p l/
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