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JUDITH T. TERRY : 4 j ? Town Hall, 53095 Main Road
TOWN CLERK : aj P.O. Box 1179
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I Southold, New York 11971
REGISTRAR OF VITAL STATISTICS •eI k= � 4. Fax (516) 765-1823
MARRIAGE OFFICER '- 402, 1Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
lFREEDOM OF INFORMATION OFFICER $V0°.I
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3242-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner JACOBS, NANCY
Mailing Address 1 2105 OLE JULE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2105 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8428
Tax Map No. section 122.00 block 5 lot 9.000
Cross Street KRAUSE ROAD
Issue Date: 8/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.,VVFU(K
Town of Southold -�® ; , CQG' , Application No.6 c / 2
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Judith T. Terry, Town Clerk .�� F �Ty
Town Hall, 53095 Main Road '• ; " .- $10.00 - Residential
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p. O. Box 1179 ‘*;!.*If $25.00 - Non-Residential
Southold, New York 11971 ® O�
Telephone .( l
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for ®apt°-
AUC dg® �7 8 1994
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OPERATION PERMIT
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SEPTIC TANK or CESSPOOL �t
Operation Permit No.
iia
Fee /
1
DATE
OWNER NAME: /4/VC�/ IACo&$
OWNER MAILING ADDRESS: /05 OeL' 1.>L (- 2,4
7)114-7-n11-v c/�
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: j r(o�- I (
TAX MAP NO. : Section (V.?-7----
Block > Lot
CROSS STREET: eie4145C W
TYPE OF SYSTEM: Septic Tank New Existing
CesspoolNew Existing O 9 aA o
Residential 1` Non-Residential
LOCATIOiN I1AP: 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.)
41 nc•< Adel (--;) 4
Signat a .f Applicant
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RECEIVED BY: ��? '�')
Town Clerk's Office
DATE: ' 1 g g