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JUbITH T. TERRY , Town Hall, 53095 Main Road
TOWN CLERK �, P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER '® t"� Fax (516) 765-1823
�/� . �! 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. 1838-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BERNARD, ROBERT AND ABBIE
Mailing Address 1 2737 MARION STREET
Mailing Address 2
City St Zip BELLMORE NY 11710-0000
Property Address 1 3745 MILL LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-785-1405
Tax Map No. section 67.00 block 2 lot 10.000
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .COW '=
Town of SoutholdOff. CS • Application No. /cif 3 '
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Judith T. Terry, Town Clerk � ' - `�I $10.00 - Residential
Town Hall, 53095 Main Road V
P. O. Box 1179 cr3 $25.00 - Non-Residential
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Southold, New York 11971 O z�y 0 ��`
Telephone a/ iftgN" o
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1Or9
•
DATE q2-
tedOWNER NAME: 411 / Am
OWNER MAILING ADDRESS: g137 j '7
&dn1'tzt) Z. y // 7/e)
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- OWNER PROPERTY ADDRESS:
,e68,7416)
OWNER TELEPHONE NUMBER: Oe) '.® e)
TAX MAP NO. : Section 67 Block � Lot
CROSS STREET: , 1f-u4 � ,4 - ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential0'3
DATE OF PREVIOUS PUMP-OUT: igi
LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
/Y1-4/14-1-41
Signature of Applicant
RECEIVED BY: -
Town Clerk's Office
DATE:
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