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./ JUDITH T.TERRY ��_ ' t: Town Hall, 53095 Main Road
TOWN CLERK ; y 2 P.O.Box 1179
REGISTRAR OF VITAL STATISTICSFax
w n► i Southold,New York 11971
16) 765-183
MARRIAGE OFFICER `414t a•���/' Telephone(516) 76521800
RECORDS MANAGEMENT OFFICER - d `T►��i
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. 3552-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HUGHES, JOANNE AND GILBERT
Mailing Address 1 BOX 1612
Mailing Address 2
City St Zip SOUTHOLD s NY 11971-0000
Property Address 1 215 COLONIAL ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5644
Tax Map No. section 79.00 block 6 lot 25.000
Cross Street EDS ROAD
Issue Date: 11/20/96 - Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
as
OFFICE OF THE TOWN CLERK S\\VFO(,r
Town of Southold CQG=� Application No.
Judith T. Terry, Town Clerk .�� `' y
Town Hall, 53095 Main Road _ $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971
Telephone 0? ••
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE � —'��
OWNER NAME: ,' v� jS'
OWNER MAILING ADDRESS: a' (9 Q71 ., - A 4 ,rte 6
.0 .7
OWNER PROPERTY ADDRESS : oV/J �a/�//6-- /gam
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section -2 9 Block Lot
CROSS STREET: � �Sk-1
TYPE OF SYSTEM: Septic Tank 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.)
)20,
ignature of App/ant
RECEIVED BY: — A, _,„( �
Town Clerk's Office
DATE: 11 /4 ��
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