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JUDITH T.TERRY �� _ Town Hall, 53095 Main Road
TOWN CLERK ; y Z P.O.Box 1179
rrr Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ` /�� Fax(516) 765-1823
MARRIAGE OFFICER ij' aO�,��
RECORDS MANAGEMENT OFFICER : .1 `1► �� 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. 3471-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HENECHAN, DR. & MRS. WILLIAM
Mailing Address 1 4800 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOCUE NY 11935-0000
Property Address 1 4800 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHCOUE NY 11935-0000
Owner Telephone No. 516-734-6800
Tax Map No. section 110.00 block 3 lot 28.000
Cross Street FLEETWOOD ROAD
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Issue Date: 5/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL) - -
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gFFICE OF THE TOWN CLERK c0FU1,,�'''
Town of Southold , Application No. 3y7/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Roadc31'
$10.00 - Residential
.
P. O. Box 1179 tri ;' $25.00 - Non-Residential
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Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 2?4,7
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,/ /
OWNER NAME: tg 4i' NITS �iU /'IleRw1 i�1 e-[(&- r 1-i11itf
OWNER MAILING ADDRESS: '�O O p Pc o21) sk/ , db-
t)
/bt)a a oIra e N`. t/ // '7 ,
OWNER PROPERTY ADDRESS: 6A /17
OWNER TELEPHONE NUMBER: 5a,- 131{- o(f)
TAX MAP NO. : Section //() Block 3 Lot
02--
, . CROSS STREET:
TYPE OF SYSTEM: Septic Tank ` ' `. • , New Existing
F" f
Cesspool t/ New Existing I/
Residential i/ 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.)
17( sit-Az4et
ut-A-eri: -
Signatu of A licant
RECEIVED BY: "
Town Clerk's Office
DATE:
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