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JUDITH T. TERRY : O Town Hall, 53095 Main Road
TOWN CLERK rrri P.O. Box 1179
6h �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ��� Fax (516) 765-1823
MARRIAGE OFFICER �' y�® •
Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER -- ® k
FREEDOM OF INFORMATION OFFICER �� i<i '
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3229-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DWYER, PAULINE
Mailing Address 1 3961 TAFT AVENUE
Mailing Address 2
City St Zip SEAFORD NY 11783-0000
Property Address 1 1355 LAKE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-781-4391
Tax Map No. section 59.00 block 5 lot 11 .000
Cross Street KENNY'S ROAD
Issue Date: 8/01/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE QF THE TOWN CLERK 'c�FFO(,-
�'•
Town of Southold ® CQG Application No.��g44
Y., ".
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - x � 7 $10.00 - Residential
P. O. Box 1179 (r) $25.00 - Non-Residential
Southold, New York 11971 O ®_t' y" �`
Telephone .( )\‘6).."
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/D. o 0
DATE ' ;2.‘s
OWNER NAME: ��_Lt. !
�—
OWNER MAILING ADDRESS: 3 , A ye. .
4ToR9 , 1�1i.tr'. /j7g3
OWNER PROPERTY ADDRESS: )3 L 1` 1 Jr I I/
sown-tom), f\! y: (?,'/ - 07-CY
S4Vn�
OWNER TELEPHONE NUMBER: (5 - � � Soy`-Fknl:cC
!/) '$l -ct3?f (VG) 7C5-2o51
TAX MAP NO. : Section Block S Lot //
CROSS STREET: ke,tits -4 3 `I?0C.c
TYPE OF SYSTEM: Septic Tank X New Existing x
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 'cant
RECEIVED BY:
Town Clerk's Office
DATE:
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, JNAUTHORIZED ALTERATION OR ADDITION
'Q rf TO THIS SURVEY IS A VIOLATION OF
SECTION 7209 OF THE NEW YORK STATE
•` _ - ` • EDUCATION LAW.
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T. •• COPIES OF THIS SURVEY MAP NOT BEARING , FSR
THE LAND SURVEYOR'S INKED SEAL 02 J.
.�1; - t ' EMBOSSED SEAL SHALL NOT BE CONSIDERED , iY
,, � r TO BC A VALID TRUE COPY
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a._� �h'prti,'a _ 4 ' GUARANTEES INDICATED ULREON SHALL P.UN
I (3�.07. ONLY TO THE PLi.SON FOR WHC.M THE SURVEY
f�)1't `"^+.,�, f" C - j ,, IS PRCFARED, A�.D 01-I HIS 55,IALF 10 THE
' "•k._,,,,� I' TITLE COMPANY, GOVLRNMEN,AL AGENCY AND
I `, � _ , LENDING INSTITUTION USED II.EEON, AND ,
• - 1 1• + 1 •, TO THE ASSIGNEES OF THE LENDI,IG INSTI-
t ITpl',,YF ' TUTION GUARANTEES AGC NOT TRANSFERABLE
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TO ADDITIONAL INSIMMONS OR SUBSEQUENT
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