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o JUDITH T.TERRY ` � Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
erg Psi Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � ��,��� Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER --- *pa" Telephone(516) 765-1800
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. 3534-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ENGELS, ETHEL D.
Mailing Address 1 1 GRENWOLDE DRIVE
Mailing Address 2
City St Zip GREAT NECK NY 11024-0000
Property Address 1 105 BEACHWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-466-9724
Tax Map No. section 116.00 block 4 lot 28.000
Cross Street DEAN DRIVE
Issue Date: 10/24/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
go
OFFICI=' Of THE TOWN CLERKOFO c/
Town of Southold � .,� • T Q =�, Application No.
Judith T. Terry, Town Clerk 6Za " ;{ t
Town Hall, 53095 Main Road , !'` I $10.00 - Residential,
ti ,�,sA
P. O. Box 1179 w � ifi ��� $25.00 - Non-Residential�,�
Southold, New York 11971 ®-74,01 �� `
4.4if
Telephone
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE -_ 'O// -qA
OWNER NAME: \-0 1 , .r •_
OWNER MAILING ADDRESS: t „
OWNER PROPERTY ADDRESS: jji-
OWNER TELEPHONE NUMBER:(0 _ ya,-9•7d4 ® C � a��e� 934, 6ag-
TAX MAP NO. : Section /14 Block 1/ Lot .95'"
/0-1-
CROSS
0-CROSS STREET �,�®c)
TYPE OF SYSTEM: Septic Tank New Existing-
Cesspool 5 New Existing
Residential 1/ 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.)
,cyz,} J
Signature of Applicant
RECEIVED BY:
Town Clerk's -Office
DATE:
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