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JUDITH T.TERRY ��� Town Hall,53095 Main Road
TOWN CLERK '
C ¢� �v�h ;� .; � � P.O.Box 1179
-'' w York 11971
New REGISTRAR OF VITAL STATISTICS Southold,
MARRIAGE OFFICER t*"28;°' ���1 Fax( Ne 765-1823
RECORDS MANAGEMENT OFFICER : ®i1 d Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ���,,,,••I/II
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3248-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DAVIS, WENDY E.
Mailing Address 1 10270 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 10270 SOUND AVENUE
Property Address 2
City St Zip MATTTIUCK NY 11952-0000
Owner Telephone No. 516-298-5070
Tax Map No. section 122.00 block 2 lot 12.000 •
Cross Street FACTORY AVENUE
Issue Date: 9/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• „„
OFFICE OF THE TOWN CLERK �c,31FOur
Town of Southold Application No. 32 V4;')Judith T. Terry, Town Clerk �� Y ,fir;• $10.00 - Residential
Town Hall, 53095 Main Road a hr
P. O. Box 1179 jx: M�`' $25.00 - Non-Residential
Southold, New York 11971 O ® ,4.- .iO�•,`
Telephone _ .( ��
(516) 765-1801 •
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE S /
OWNER NAME: k AD cA P .•_ �& 5
OWNER MAILING ADDRESS: 10 c)--/O S LLrl d 1-1ye ,•
OWNER PROPERTY ADDRESS: i
OWNER TELEPHONE NUMBER: 'r ,cj,' •— 66 (�
TAX MAP NO. : Section la-d— Block - Lot
CROSS STREET: —�� ��9 %:•-1/4,_ ( A-
TYPE
OF SYSTEM: Septic Tank / New Existing /
Cesspool +/ New Existing ✓
Residential Non-Residential
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:
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Q C LI-CI I
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