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JUDITH T.TERRY �11 �• Town Hall, 53095 Main Road
TOWN CLERK Q '' ..�u P.O.Box 1179
u ',1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ® 1 4 1 1823
Fax(516)765-
MARRIAGE OFFICER = 4® , tk3t' Telephone(516) -1823 765-1800
RECORDS MANAGEMENT OFFICER ti
FREEDOM OF INFORMATION OFFICER ."'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3382-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DILWORTH, THERESA
Mailing Address 1 310 EAST 55TH STRRET, APT. 12E
Mailing Address 2
City St Zip NEW YORK NY 10022-0000
Property Address 1 3755 ALDRICH EXT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 212-753-1025
Tax Map No. section 112.00 block 1 lot 8.005
Cross Street SOUND AVENUE
Issue Date: 9/14/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
+ = o, •
OFFICE OF THE TOWN CLERK FIV(
Town of Southold e4--% Application No. 3 3
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - $10.00 - Residential
P. O. Box 1179 cry Z' $25.00 - Non-Residential
Southold, New York 11971 OOr,�`
Telephone : .� * 0O'�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
141 CK
DATE
OWNER NAME: Le,C'5
OWNER MAILING ADDRESS: ' �'" ' (Ae( : I L
1\q I 001-2
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 22 —to),
TAX MAP NO. : Section t (,)-- Block ® I Lot 8
CROSS STREET: Gau.„ 4-CIOU-Q
TYPE OF SYSTEM: Septic Tank New v\ Existing
Cesspool New Existing
Residential 4-- 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.)
----717-‘115(c
Signature of pplica
RECEIVED BY:
Town CI rk's Office
DATE:
C?l/3 - 1406 9-/c- 94
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(I) eel \w Dec /3, /994- (
` MAR. 24, 1995 (gar.AI
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- June 9, /995 (FL