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JUDITH T. TERRY <, d Town Hall, 53095 Main Road
TOWN CLERK ' s , kt� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER # r Fax (516) 765-1823
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�' ��r Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1739-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BRICKELL, MARK AND OTHERS
Mailing Address 1 3075 BAY AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3075 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 212-648-2418
Tax Map No. section 144.00 block 5 lot 10.000
Cross Street PECONIC BAY BOULEVARD
Date Of Last Pump Out 0/00/00
Issue Date: 8/27/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •c� FO(,I'"
Town of Southold Q C'� - Application No. /737
Judith T. Terry, Town Clerk . ., ,;` �•; y
Town Hall, 53095 Main Road
$10.00 - Residential 1,-2
P. O. Box 1179 v' K:"r ; $25.00 - Non-Residential
Southold, New York 11971 xt *-$
Telephone = j( * % ;1 °
° •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for
Re: f qL - 5-10 q-q49
- - OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O
DATE AUGUST' s( l gv
OWNER NAME: l.1,+' I< C. JC/COR.-e._ 21 al• •
OWNER MAILING ADDRESS: 3o ?S ,d4y fyveAlt
-ruck. dew Yo R4 It 95,E
---- OWNER-PROPERTY ADDRESS. 54-1.4 -- - - - - - - -- - -
OWNER TELEPHONE NUMBER: OPPicEs (2/2-) 6(0 2V/49
TAX MAP NO. : Section Block Lot
CROSS STREET: P2oPeRr7 1.OcfTeb sir La45TEaN SIDE of" tnr"r sc77o
of ¢Py �vE7vvE ,�I� 8Ry FovLVVA-07-A
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4PP2oK Oa 7 7
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.)
- 41 7. //
Signature of Applicant
RECEIVED BY: - - •
-Town Clerk's Office
DATE: •
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