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JUDITH T.TERRY ,,, *� Town Hall, 53095 Main Road
TOWN CLERK ^ a P.O.Box 1179
''4 y 1�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS "% �1 Fax(516)765-1823
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MARRIAGE OFFICER ��� Telephone
RECORDS MANAGEMENT OFFICER ‘-.27V1 �*� ���� P (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. 3365-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BAUER, ART
Mailing Address 1 P. O. BOX 404
Mailing Address 2
City St Zip SHOREHAM NY 11786-0000
Property Address 1 MILL LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-744-0188
Tax Map No. section 107.00 block 4 lot 2.008
Cross Street WICKHAM AVENUE
Issue Date: 7/28/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
A - ii ii.
OFFICE OF THE TOWN CLERK c�\FFD(,��
1 Town of Southold Q C' -
OG Application No33 Cos
Judith T. Terry, Town Clerk
Town Hall, :e53095 Main Road -� I $10.00 - Residential
^r
O. Box 1179
Southod, New York 11971 cr $25.00 - Non-Residential
Telephone _Q( `tt
(516) 765-1801in I
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.pO S K
Fee $ \C),•, 0
DATE 1 - 9S.
OWNER NAME: APT RhqVE
OWNER MAILING ADDRESS: PO ')k 1-10(-1
-- OWNER PROPERTY ADDRESS: 'j\ILL LA
V\A —rVCk )—
OWNER
OWNER TELEPHONE NUMBER: S/ 9--oii3
TAX MAP NO. : Section \®1 Block Lot + O O
CROSS STREET: MCi \4q Mei?
TYPE OF SYSTEM: Septic Tank goo New V Existing
Cesspool New k Existing
Residential k 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: ,(/e ,��'�
T
own Clerk's Office
--- DATE: �(��
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