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JUDITH T. TERRY % er-',r � rt� • Town Hall, 53095 Main Road
TOWN CLERK V,; ,t ° rrt P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ``" �� Southold, New York 11971
MARRIAGE OFFICER c ` ��� Fax (516) 765-1823
��,t Telephone (516) 765-1801' 01
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1766-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOSSLER, LOUISE
Mailing Address 1 730 SOUTH OAKWOOD DRIVE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 530 SOUTH OAKWOOD DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4585
Tax Map No. section 145.00 block 3 lot 6.000
Cross Street PECONIC BAY BLVD
Date Of Last Pump Out 0/00/00
Issue Date: 9/25/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK PFFD
Town of Southold % x>- CQ Application No./ 76
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Judith T. Terry, Town Clerk �� k.
Town Hall, 53095 Main Road a KV
$10.00 - Residential
P. O. Box 1179 v' tg.k F�' i�% $25.00 - Non-Residential
Southold, New York 11971 O �Y! Or/-
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Telephone ' 1•
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for - ,f
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.( 7 (e l
Fee $ /€ ;
i
DATE tc:2
OWNER NAME: L0 u l5 �� t' /�
OWNER MAILING ADDRESS: SiX /9,-ie c a 4-; y-
44.9.,..e. --,7 / j/ u1y ?-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: a%e..- KS
TAX MAP NO. : Section /l 3 BlockO3/,( Lot ,0D(�,
1
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CROSS STREET: --&,-3, v jr- R�J17 RAU
TYPE OF SYSTEM: Septic Tank New Existing
.. > - Cesspool 6/- New Existing 1/' --
..
r.. Residential V Non-Residential ,
DATE OF PREVIOUS PUMP-OUT:
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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4Sig ature of Applicant
RECEIVED BY: 4
Town Clerk's Office
DATE: RECEIVER , -: rciA
9 . 4
SEP 2 51991 v, 0
town GtertR Southold Eh% /.I