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JUDITH T.TERRY �� lit• Town Hall, 53095 Main Road
TOWN CLERK N $ P.O. Box 1179
47$ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ‘ ® Fax 765-1823
MARRIAGE OFFICER �� ®� ��®,V•es. Telephone(516)(516) -18765-3
RECORDS MANAGEMENT OFFICER - es
1800
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. 3667-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DOERINC, ROBERT
Mailing Address 1 975 ORIOLE DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 975 ORIOLE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3395
Tax Map No. section 50.00 block 6 of 15.035
Cross Street LISA DRIVE
Issue Date: 7/30/97 Judith T. Terrf
Southold Town Clerk
(TOWN SEAL)
•i ��� \
OFFICE OF THE TOWN CLERK 'S�FFO(k��"
Town of,Southold , �� QG'_ Application No. 36,67
Judith T. Ter*, Town ClerkTown Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u' $25.00 - Non-Residential
Southold, New York 11971 O �
X0. /�`
Telephone Ji[ ��,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
CAefo / for
16 ( 1 R OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1 —;a\
OWNER NAME: R p , &-p Y D L� i..) 6
OWNER MAILING ADDRESS: rG ® P. i o L & )
3 u p D /L.D, L- 119 `'9/
OWNER PROPERTY ADDRESS: E /1- 1-1C
OWNER TELEPHONE NUMBER: ''7 ( S-- 3,3 96'
TAX MAP NO. : Section 6-4' Block 6 Lot /.5-. 3 3
CROSS STREET: L 1 $ A b2
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.)
111,11° I .
Signature of Applicant
RECEIVED BY: w✓`�1�`---y'
/ wn /Clerk's Office
DATE: 7 /act
• Ia,' ;1• ,�t • ,tr °•,'}
SUFFOLK COUNTY DEPARTMENT OP HEALTH SERVICES .i - '
�' '
"`' APPROVAL OF CONSTRUCTED WORKS FOR
r, A SLNGLE FAMILY RESIDENCE
`+ Dato f Ul 1 4 1907 H.s.Ret Imo. I o- ?7- o O 3 ( ,.. .
The sewage disposal and weer soppb'fcititie',t at this location haw;been
inspected and/or certified by this Depaftnient.or other agmcies end Brand to
be satisYhctnry FOR P . 'S' ., M OF 47,B At I .S. - ' i
' St$hc A.Costa,P.E.,'Chief— . -
• • Office of Water and Wastewater Management _ "
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