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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
t� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = �® .t. �� Fax (516) 765-1823
MARRIAGE OFFICER .j' �® ,�� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER =7UJ I a I'
FREEDOM OF INFORMATION OFFICER sir/
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3266-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HOMMEL, DAVID AND JEANETTE
Mailing Address 1 4000 MAIN ROAD
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 4000 MAIN ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-9181
Tax Map No. section 125.00 block 3 lot 11 .000
Cross Street ALDRICH LANE
Issue Date: 10/18/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF' IvE~OF THE TOWN CLERK c31FO(,� /
Town of Southold &,.% • Q ,� Application No. (.3.2
Judith T. Terry, Town Clerk .� k �► �
Town Hall, 53095 Main Road t' -� $10.00 - Residential X_
P. 0. Box 1179 trs x ; $25.00 - Non-Residential
Southold, New York 11971 O`' r •`�
Telephone _ VI `�oi'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 10
1
OWNER NAME:: ) \)`tiA, CA.rc1,. h� � g ,)yn Yl'1 ,
OWNER' MAILING ADDRESS: 4000 Oa:0 l\��,
OWNER PROPERTY ADDRESS: 3 f f'
OWNER TELEPHONE NUMBER: ,3617 — � I
TAX MAP NO. : _Section a 5 Block d '5 Lot l I
CROSS STREET: MaA04\ \,,c41--v•-e„
TYPE OF SYSTEM: Septic Tank i New Existing
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.)
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l... e �.
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( Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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Mrs.Jeanette C.Hommel
Main Rd
I Laurel NY 11948
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11110 _
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