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JUDITH T.TERRY irt Town Hall, 53095 Main Road
TOWN CLERK r !' $ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 4 ® ` Southold,New York 11971
® �� Fax(516) 765-1823
MARRIAGE OFFICER � � ��
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RECORDS MANAGEMENT OFFICER gEgTelephone(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. 3698-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner IRIS, GERALD
Mailing Address 1 P. O. BOX 1568
Mailing Address 2
City St Zip SOUTHLD NY 11971-0000
Property Address 1 225 WAMPUM WAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-9456
Tax Map No. section 87.00 block 2 lot 36.000
Cross Street WIGWAM WAY
Issue Date: 10/07/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIC E• O,F ,THE TOWN CLERK .c.§WFOUr
Town of Southold Application No.��
Judith T. Terry, Town Clerk •'.`'
Town Hall, 53095 Main Road g $10.00 - Residential
P. O. Box 1179 to 4,) $25.00 - Non-Residential
Southold, New York 11971 O *.$
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
•for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
/® /`? 1
OWNER NAME: aci- �� 1S
OWNER MAILING ADDRESS: , Sv P<- Ic 6 sr
OWNER PROPERTY ADDRESS : s— tA) —1 , 'f c� )44 ws— J LD1 Y
OWNER TELEPHONE NUMBER: ( c1c) 7 �— -)
EDi 61-14-riA)
TAX MA Section �7 BSW o Lot 3'�
CROSS STREET: W 1 1,0 IAA W Goo (2- ii,e1.00oLFAiG Nisi
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool e/ 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.)
ignature of Applicant
RECEIVED BY:
Town Clerk's Office •
•
DATE:
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