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JUDITH T.TERRY �� ; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS `a . Fax Fax(516) 765-1823
MARRIAGE OFFICER a® ••
RECORDS MANAGEMENT OFFICER : 49.1 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. 3465-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HERZICH, MARIE
Mailing Address 1 370 TERRY COURT
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 370 TERRY COURT
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2556
Tax Map No. section 59.00 block 11 lot 12.000
Cross Street TUCKERS LANE
Issue Date: 5/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFFICE Or THE TOWN CLERK
•
COFoLA' _31711,9
Town of Southold CQG Application No.
Judith T. Terry, Town Clerk .� ; , :`
Town Hall, 53095 Main Road -< I $10.00 - Residential
P. O. Box 1179 v' =?= i�`' $25.00 - Non-Residential
Southold, New York 11971
Telephone ( * y1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE (5.---41"
OWNER NAME: hid/li/ efr �/6A
OWNER MAILING ADDRESS: ,3 7d /t'� e
OWNER PROPERTY ADDRESS : 6&I e.
OWNER TELEPHONE NUMBER: S>Z -- �5 � ), cST6
TAX MAP NO. : Section 97,3 5-dy Block OO9-%'-/2- Lot
CROSS STREET: 74' G/?e/d3 Lal/ e.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool /7 New Existing
Residential v 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 Applicant
RECEIVED BY:
To n Clerk's Office
DATE: fz5
p..6
1966
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