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JUDITH T. TERRY -. : Town Hall, 53095 Main Road
TOWN CLERK "ac P.O. Box 1179
REGISTRAR OF VITAL STATISTICS % Southold, New York 11971
MARRIAGE OFFICER ‘�� �� Fax (516) 765-1823
�,yol 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. 3141-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BACHRACH, HOWARD L.
Mailing Address 1 P. O. BOX 1054
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 355 DAYTON ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3342
Tax Map No. section 71 .00 block 1 lot 31 .000
Cross Street NORTH PARISH DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 11/16/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
A
OFFICE t,ERK COMA' �� , f�
Town _ , ('• 1G
id Application No. t-(
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road =* 1 $10.00 - Residential (/ -
P. O. Box 1179 cn ;1 'moi ; $25.00 - Non-Residential
Southold, New York 11971 O ' ` � �%
Telephone '4 •� �� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
Fee $ /D
DATE &�71:- z6, /97 3
OWNER NAME: jwft/zp 2. .ger/ cn
OWNER MAILING ADDRESS: 3s-s -2)/4-Yron) 649
Pa', /3ox' /05Y Lc a-� 4/Y 1/97/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 0%0 76r-3 3 yZ
TAX MAP NO. : Section Block / Lot `5/
CROSS STREET: v1f fa44; IA-• -D•
TYPE OF SYSTEM: Septic Tank New Existing
Z Cesspools i/ New Existing
Residential ..✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
•
LOCATION MAP: Must befattache hereto before permit may be issued.
(Locate • ing and system; give north arrow and feet
of distance, approximately, to building and closest road.)
cua® /
mil•.nature of Applicant
RECEIVED BY: Lt*
Town Clerk's Office
• DATE: 6 (Z Gt ( �-3
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