HomeMy WebLinkAboutBernath V,4,-7,-* Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY �� =0!�' FAX(516)765-1823
�� TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 962-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BERNATH, PAUL
Mailing Address 1 34 BRAY AVNEUE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 34 BRAY AVENUE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-9422
Tax Map No. section 126.00 block 8 lot 16.000
Cross Street WELLS ROAD
Date Of Last Pump Out 0/00/84
Issue Date: 12/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE' OF THE TOWN CLERK ��FD
Town of Southold ��� _ Application No. v
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road � :'� Residential y4
P. O. Box 1179 y` rt" i ; Non-Residential
Southold, New York 11971 O
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Telephone _ �,�j j
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(516) - 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 9(,
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Fee $ /d
DATE
OWNER NAME:
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OWNER MAILING ADDRESS: '3(1( 13P ✓ iJi
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OWNER PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER: 2% 9f22...
TAX MAP NO. : Section /2-,6 Block Lot
CROSS STREET: �f.�LG� ;�j� -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing y
Residential Non-Residential
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DATE OF PREVIOUS PUMP-OUT: PT-/9r ?ash&; e a<'o or
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.)
Ade 74( 3°4114-
Signature of Applicant
RECEIVED BY: G .`•
Town .Clerk's ffice
DATE: ?3 l �,� Y NICER,'ED
DEC 1 9 1988
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