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JUDITH T.TERRY .:21• Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER L V. ® ilk Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER . 11 �roe'�� 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. 3699-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HANSEN, VALERIE
Mailing Address 1 835 SHIPS DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 835 SHIPS DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5393
Tax Map No. section 79.00 block 3 lot 33.000
Cross Street NORTH BAYVIEW ROAD
Issue Date: 10/09/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFS�F
ICE OF THE TOWN CLERK O.c31 .•
Town of Southold (4% Application No.
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 h�i �`' $25.00 - Non-Residential
Southold, New York 11971
Telephone *e.( 4[4 NO' "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • •
DATE
OWNER NAME: ?ra.0-17qazIAA-Q-
OWNER MAILING ADDRESS: g 3
1197 I
OWNER PROPERTY ADDRESS: �'.3.3/ . j }v' -
i
• _._. E Y. 1tci7I
OWNER TELEPHONE NUMBER: l� to
TAX MAP NO. : Section 7 Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing v
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.)
C:Re.„..vua_syy2_/
Signature of Applicant
RECEIVED BY: ///
Town Clerk's 0 rice
DATE: M/9/9
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