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7K Town Hall, 53095 Main Road
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P.O. Box 1179
s Southold, New York 11971
JUDITH T.TERRY `�� TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3592-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner EURING, KENNETH AND CAROL
Mailing Address 1 P. O. BOX 1716
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 280 WAVECREST LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-2618
Tax Map No. section 100.00 block 3 lot 3.000
Cross Street REEVE ROAD
Issue Date: 2/28/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ��FU
Town of Sctrthold �� elQ% Application No.
Judith T. Terry; Town Clerk i1:: yTown Hall, 53f5 -< 7 $10.00 - Residential �/
P. O. Box 1179 u' : `` �' i ;' $25.00 - Non-Residential
Southold, New York 11971
Telephone -o.( 4 $
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. I1
Fee $ •
DATE 2.- 7
OWNER NAME: /14///7C' J Cnro / �12/x1
'
OWNER MAILING ADDRESS: /7 /6 •
/0•22 ifvGk ti`% //pis a
OWNER PROPERTY ADDRESS: ,9 �.4veere:5'74 LA,-/e--
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,'e—OWNER L 1\ 1 LI 1 1 T
I.471",/7/2/C_ //,'S--2
OWNER TELEPHONE NUMBER: c el '--A61�
„P/5/". /Ovv
TAX MAP NO. : Section /00 Block v? Lot 3
-CROSS STREET: gee
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.)
Signature of Ap scant
RECEIVED BY: ,I. 4 ,_.
`Town' Clerk's' Office
DATE: F / -
SUFFOLK CO. HEALTH DEPT. APPROVAL
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