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JUDITH T.TERRY ���� �j Town Hall, 53095 Main Road
TOWN CLERK Z ; P.O. Box 1179
Ivy �$ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �%.®� ����� Fax(516) 765-1823
MARRIAGE OFFICER � si;o . Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER 't`��
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. 3492-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HENRY, JOHN P.
Mailing Address 1 P. O. BOX 95
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 95 MIDWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7280
Tax Map No. section 110.00 block 3 lot 32.000
Cross Street PEQUASH AVENUE
Issue Date: 8/15/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ,c.31FRat \_71.F, ,
Town of Southold �% CQ %� Application No.
Judith T. Terry, Town Clerk .� .+
Town Hall, 53095 Main Road r ', sh 1 $10.00 - Residential_ �.
P. O. Box 1179 v' :F '3.7,';!;!' n ,' $25.00 - Non-Residential
Southold, New York 11971 O '' ''.&,;c-
,°�V ,;c- .4
Telephone = j , `'1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION ;/
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE atty q 0' 7‘
OWNER NAME: Joho P �/C4/e
y
OWNER MAILING ADDRESS: 'PO go.X1/� Y.K.
1 �,tc40 C uE" /l /193./
OWNER PROPERTY ADDRESS : 9,,c/fifbtuoob / ..D.
Cur cdo --uF /-'r /IY„3,r/
OWNER TELEPHONE NUMBER: 736_/y?G
TAX MAP NO. : Section No Block 3 Lot .32
CROSS STREET: 'PC 6?ctRS ti /girt'.
TYPE OF SYSTEM: Septic Tank . New Existing
Cesspool X New X Existing
Residential x 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.)
0 , 4 -/
i.ig ature of Appfant
RECEIVED BY: O� C.,4liij
Town CI rk's Office
DATE: 7 (-\2� %`Ick
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