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JUDITH T. TERRY . Town Hall, 53095 Main Road
TOWN CLERK p TP.O. Box 1179
REGISTRAR OF VITAL STATISTICScfs Southold, New York 11971
MARRIAGE OFFICER t-�Q ®�' �� Fax (516) 765-1823
#449./ Ali 1D .1 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. 2081-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANDERSON, STUART P.
Mailing Address 1 517 CERVINA DRIVE NORTH
Mailing Address 2
City St Zip VENICE FL 34292-0000
Property Address 1 1230 BAY AVENUE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 813-484-0858
Tax Map No. section 31 .100 block 8 lot 19.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ' PFFD ,
Town of Southold % "� CQ - Application No. a 0
et-
Judith T. Terry, Town Clerk ; o• �•
Town Hall, 53095 Main Road - ' ,- - :� $10.00 - Residential
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p. O. Box 1179 �VI. ��s�Y.-• '��% $25.00 - Non-Residential
Southold, New York 11971 O."_. ' �0 ��`
Telephone 09
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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.
Fee $ •
DATE f). /1n 11'93
OWNER NAME: . )1-1)4 (....r
)1-1) �, A fAer oit.i
OWNER MAILING ADDRESS: 6"-11 06—g 'tile )e/V' Nhei'crl
lre- e a 34 aqx.
OWNER PROPERTY ADDRESS: ) 30 A3 - ,Ati'
Ei3s-r N • 14/c A
OWNER TELEPHONE NUMBER: //3 +24- dg'c8 1
TAX MAP NO. : Section 4-73 g g-q Block .. / - 0 Lot I q
t_, ; - CROSS STREET:
:TYPE; OF-,SYSTEM":- Septic-Tank-�----- — - New Existing
Cesspool / New Existing
Residential / Non-Residential -
DATE OF PREVIOUS PUMP-OUT: /U Oitk
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.)
Y { g"C&)
Signature of Applicant
RECEIVED-BY:. _ - - . ;-,...- - - - - - -- - - __ . -
Town Clerk's Office
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