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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS V ��' Fax (516) 765-1823
MARRIAGE OFFICER =e,` s®
RECORDS MANAGEMENT OFFICER + $ 0ISP Telephone (516) 765-1801
FREEDOM OF INFORMATION OFFICER
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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. 3234-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DEVRIES, ALICE AND PATRICIA
Mailing Address 1 3400 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3400 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5159
Tax Map No. section 115.00 block 17 lot 11 .000
Cross Street THERESA DRIVE
Issue Date: 8/16/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE,OF THE TOWN CLERK cvFFU/i.
Town of Southold �� F CQ ' , Application No. 3 a3 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< $10.00 - Residential
p. O. Box 1179 cryo ' .` $25.00 - Non-Residential
Southold, New York 11971 .
is.� •z$
Telephone ' °'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /d"
DATE(91 G /ff
OWNER NAME: A,/- lG I r� f ll,S — RITR(Cr I/8
OWNER MAILING ADDRESS: 3 Dd L /3p //0 I.: De
OWNER PROPERTY ADDRESS: A R a v 1,-
OWNER TELEPHONE NUMBER: 91- 6-2_3--?
TAX MAP NO. : Section �,4 r Block /7 Lot //
CROSS STREET: •7--�/“)LS4 i
TYPE OF SYSTEM: Septic Tank New Existing L
Cesspool NewExisting i/
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.)
A4.6e:tatet.:6
1,
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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