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Town Hall, 53095 Main Road
P.O. Box 1179
` /y,/ rrti Si Southold, New York 11971
JUDITH T.TERRY "= �,,o, TELEPHONE) 18
16)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. 1232-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BRALL, ELLA C/O BERYL WILCOX
Mailing Address 1 53605 NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 56305 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2151
Tax Map No. section 44.00 block 1 lot 23.000
Cross Street ALBERTSON LANE
Date Of Last Pump Out 8/00/54
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •� 1����
Town of Southold
�� .� CQG Application No. /z3 �
Judith T. Terry, 7,'own Clerk w k y
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn 'ti - _ .'
�y � `� ��.:,,�3°� � $25.00 - Non-Residential
Southold, New York 11971 p ® � `
Telephone 1q1 • ,
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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.
Fee $ �,O
DATE ?i�0t `�, �
OWNER NAME: 1341�0 J t/6X. C,0
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OWNER MAILING ADDRESS: 610.36S tI0R-TAI,. -
OWNER PROPERTY ADDRESS: •ck ;,-y
OWNER TELEPHONE NUMBER:
dZb aC5.00
TAX MAP NO. : Section /,�1 to 00 Block O(a C9 0 Lot 1-1-24=1:= 9
CROSS STREET: \\cj 2,6,a \. yti e. 90yten ,7)01, -091-3
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ✓
Residential v'y Non-Residential
DATE OF PREVIOUS PUMP-OUT: 033,p0a31I c1 4(
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE: nrommp
AUG 21 1!-,4,-
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