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JUDITH T.TERRY ti1,_ < ` Town Hall, 53095 Main Road
TOWN CLERK ; y _ ; P.O. Box 1179
v. t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ` Fax(516)765-1823
MARRIAGE OFFICER Wik aO�,���
RECORDS MANAGEMENT OFFICER - o.( jig i
It ,, Fax
(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. 3459-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ERIKSEN, MARY M.
Mailing Address 1 875 EUGENES ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 875 EUGENES ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6984
Tax Map No. section 97.00 block 2 lot 19.000
Cross Street MAIN ROAD
Issue Date: 4/23/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1_1511FICE OF THE TOWN CLERK COMA' --
Town
-
Town of Southold . • CQG'� Application No.3 5/57
Judith T. Terry, Town Clerk ���,.,f u •` !/
Town Hall, 53095 Main Road -`L $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 0` "J :
Telephone --70/ 41-Nros, to
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION -
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • DATE i//J�1�G
OWNER NAME: PI, ETZ I L t�
OWNER MAILING ADDRESS: 57.S `fid -�
/ )7
OWNER PROPERTY ADDRESS : -
OWNER TELEPHONE NUMBER: (S/4) 7 y— G red-
a--1?
TAX MAP NO. : Section 7 �eC( Block % 7 Lot
'CROSS STREET:
TYPE_,OF.SYSTEM: Septic='Tank ' v= - - New Existing
Cesspool New Existing
Residential IV 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.)
Si ature of Applicant
RECEIVED. BY:- -
Town Clerk's Office I_
DATE: =
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