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JUDITH T. TERRY � � Town Hall, 53095 Main Road
TOWN CLERK Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T ; Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
�`® �®��� Telephone (516) 765-1801
1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1665-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BASSIS, STEVEN C.
Mailing Address 1 213 THIRD STREET
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 213 THIRD STREET
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5066
Tax Map No. section 126.00 block 7 lot 10.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
L1
OFFICE OF- THE TOWN CLERK ��FFCt //
Town of Southold t� C'�G- Application No. ! ccs
Judith T. Terry, Town Clerk a-' `` y
Town Hall, 53095 Main Road - ,;� :4= $10.00 - Residential
P. O. Box 1179 Lfl
*V $25.00 - Non-Residential
Southold, New York 11971 ��`
Telephone = j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE '2-7/0'
OWNER NAME: $ --e h .Q, 15,e. s r /•
d'
OWNER MAILING ADDRESS: - ( ) rr� S7'
OWNER PROPERTY ADDRESS: 5
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 1,a(,,,00 Block 7,00 Lot -1 ;4010,000/
CROSS STREET: 3,1 AO-t
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ( New Existing S
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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