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4 JUDITH T.TERRY ��� y�c Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
yy. Southold,New York 11971
REGISTRAR OF VITAL STATISTICS V O �
MARRIAGE OFFICER �� �� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER t,( 1ao 1i� 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. 3654-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ISAAC, MORRIS
Mailing Address 1 P. O. BOX 1687
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 522 BAILEY AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-298-5895
Tax Map No. section 34.00 block 4 lot 9.000
Cross Street ROUTE 25
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Issue Date: 6/26/97 P� Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FFO 2/
"Town of Southold ��� . Application No. 36,5
Judith T. Terry, Town Clerk .� xs�� ' '.-;
Town Hall, 53095 Main Road -� 1 $10.00 - Residential
P. O. Box 1179 v' rix ' 1-` :' $25.00 - Non-Residential
Southold, New York 11971v ® .r- **-` �� ��`
Telephone .( 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: D
OWNER MAILING ADDRESS: IT? (9 . O K l io i97
OWNER -PROPERTY ADDRESS: 5-2A-- a - u -
OWNER TELEPHONE NUMBER: 29 S 5-
TAX MAP NO. : Section 3 Block -/ Lot q
CROSS STREET: P'/"1 -
TYPE OF SYSTEM-:- -S'epti'c'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.)
faelaet,c
Signature of Applicant
•
RECEIVED BY: - - -
' Towri Clerk's Office
DATE,:
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