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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® � t P.O. Box 1179
REGISTRAR OF VITAL STATISTICS I3P .�` Southold, New York 11971
MARRIAGE OFFICER V Fax (516) 765-1823
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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. 1988-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANRIC, ROBERT J.
Mailing Address 1 158 BROADWAY
Mailing Address 2
City St Zip NORWOOD NJ 07648-0000
Property Address 1 1595 AQUAVIEW AVENUE EXT.
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 201-768-5174
Tax Map No. section 22.00 block 2 lot 4.000
Cross Street CEDAR DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
Or . E"OF THE TOWN CLERK �FFD�����
Town of Southold �� :, C� Application No. Heir
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ' $10.00 - Residential
P. 0. Box 1179 1 . $25.00 - Non-Residential
Southold, New York 11971
Telephone (
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /0 - /3 -
OWNER
$ -OWNER NAME: AiZle7 4/1/00eie
OWNER MAILING ADDRESS: /'.:,5 ? f �/�IJ a/,4-y
OWNER PROPERTY-ADDRESS: 4
OWNER TELEPHONE NUMBER: 2(4 i 76 ? X754
TAX MAP NO. : Section "22 Block 2. Lot
CROSS STREET:
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TYPE OF'SY-STEM: Septic) Tank - --New Existing
Cesspool .f New Existing 1
Residential ,/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: fliem
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.)
444SJ, natApplicant
RECEIVED- BY: .- =
Town Clerk's Off.'
C�In
DATE:
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