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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O.r P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER VQ, -'/' Fax (516) 765-1823
em) 61 ,i#$ 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. 1946-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOCKSEL, ARNOLD
Mailing Address 1 78 MILLER BLVD.
Mailing Address 2
City St Zip SYOSSET NY 11791-0000
Property Address 1 620 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5990
Tax Map No. section 143.00 block 1 lot 8.000
Cross Street - MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/21/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ICOFGIL- =
Town of Southold �� Application No. OY
Judith T. Terry, Town Clerkk -r y •
Town Hall, 53095 Main Road �'''^ l $10.00 - Residential
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P. O. Box 1179 '�.r ,,. �°�YF��' 'moi ;' $25.00 - Non-Residential
Southold, New York 11971 Oho _.�0���`
Telephone 'o
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE / fL
OWNER NAME:
OWNER MAILING ADDRESS: 78r 'WtL--t t ,e 041>
57/0 56 7' 4 V I / ? Q/-
OWNER PROPERTY ADDRESS: lrt sap
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OWNER TELEPHONE NUMBER:Zif-c9 FQ 1,, 02,92d.
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TAX MAP NO. : Section ! 43 BYock P Lot
CROSS STREET:
TYPE OF SYSTEM: _ Septic:Tank , New Existing a
Cesspool New Existing 7,--
Residential
Residential `� Non-Residential �"
DATE OF PREVIOUS PUMP-OUT: J4' 7
/U �9 �-
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 - pplicant
•
RECEIVED BY:
- Town Clerk's Office
DATE:
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