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JUDITH T. TERRY Z Town Hall, 53095 Main Road
TOWN CLERK ® r=m • P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ' V®
�. �� Fax (516) 765-1823
MARRIAGE OFFICER ' A® ,I' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER L.:4m 4' Il -
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. 3286-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HARVEY, CARROLL AND STELLA
Mailing Address 1 P. O. BOX 351
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2200 WICKHAM AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8767
Tax Map No. section 139.00 block 3 lot 25.000
Cross Street BAYER ROAD
Issue Date: 12/05/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF TJIE TOWN CLERK (NCOFDUrC• - -_ l
Town of Southold Q Application No32.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road gz< - . $10.00 - Residential
P. O. Box 1179 u-3 h�i ;' $25.00 - Non-Residential
Southold, New York 11971 O y` µ O '��
Telephone �j * �� �'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE NM- 3'O /r7
OWNER NAME: e°A RRO(J. 5775.-1441c F
OWNER MAILING ADDRESS: /- .) • /SOX 35/
OWNER PROPERTY ADDRESS: O Q tAf/ R/M-M.
OWNER TELEPHONE NUMBER: -qG/
TAX MAP NO. : Section j 3 y-. 3 - 2 Block 3 Lot ,;Z_r
CROSS STREET: FA QQ.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 1Z
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.)
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Signature of pplic
RECEIVED BY:
Town Clerk's Office
DATE:
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