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JUDITH T.TERRY _ ��i Town Hall, 53095 Main Road
TOWN CLERK ; y Z P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS `
MARRIAGE OFFICER .1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER =4®.` � `1►►�of�� Fax
(516) 765-1800
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. 3538-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BASCOMB, ALFRED AND JOAN
Mailing Address 1 P. O. BOX 432
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2105 WESTVIEW DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4456
Tax Map No. section 107.00 block 7 lot 2.000
Cross Street WOODCLIFF DRIVE
Issue Date: 10/28/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �5vFF •
Town of Southold �� CD . Application No. a_6-
Judith T. Terry, Town Clerkri �,
Town Hall, 53095 Main Road T ` }_, $10.00 - Residential_
P. O. Box 1179 X 1-& •; �' $25.00 - Non-Residential _
Southold, New York 11971 ® �o +�` J�^
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D, 043
DATE /0/2g/f4"
OWNER NAME: 44/4�741 W 9 -7;4A/ .0 ,B4S4`c>"/
OWNER MAILING ADDRESS: /` 49"X 4132
41-4 77/22/c /< /►/y
OWNER PROPERTY ADDRESS: /o0f- 4^.S-T7/'-'4 h/ 1Q4iV4"
• 1214 777--7Z<A- /t/7 /19 4
OWNER TELEPHONE NUMBER: .,,j74 . 29`x-
TAX MAP NO. : Section /G 7 Block "7 Lot 2.
CROSS STREET: Wood /fit!/,`
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ' New Existing 1/
Residential 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.)
Signature of Applicant
RECEIVED BY: /L/
Town
Clerk's •ffice
DATE: /0/e2 ��j ey9.c/5d. 7
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MAP OF PROP E[2T Y 4------50.,4
SURVEYED PO(2_
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MATTITUC kL SUFE CO.TAX MAP : /CM- 107-7-2, 171-i,. 2ODE1s
TOWN OF SOUT -4JL D 1 N` . ��' �Gl6e .,
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