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JUDITH T.TERRY
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TOWN CLERK TELEPHONE(516)765-1801
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. 1132-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOLLING, HAROLD
Mailing Address 1 RR #2, BOX 15C, MAIN ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-3824
Tax Map No. section 125.00 block 1 lot 18.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/02/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK: ���F.�F.01,;
Town of Southold � COQ. Application No._ f/
Judith T. Terry, Town Clerk /
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Town Hall, 53095 Main Road k, .•C Residential (/
P. O. Box 1179 .. �< 7 ;' Non-Residential
Southold, New York 11971 O ® ''
Telephone - ,( -`.� '.
(516) 765-1801
,TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
RECI., APPLICATION
G 1988 _ -- —----
`(OU�UOeigE "pCd OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0r. D ;
DATE
•
OWNER NAME: are la( Re' (frit
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OWNER MAILING ADDRESS: � � ge•X /e matil ,
OWNER PROPERTY ADDRESS: fika<p1 Pejact ���/ dv� 2fge
OWNER TELEPHONE NUMBER:- ,2-9w- 3g�f,G
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TAX MAP NO. : Section l akr Block / Lot I o
CROSS STREET: g(7Z fi , / /'yIGL�f jFCc(
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t/ New Existing
Residential t/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: /y�q�- r'e --
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.)
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Signature o A licant
RECEIVED BY: ?/ �� ��, •
o n C er se,0 ice
DATE: ��°
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