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JUDITH T.TERRY �� = . Town Hall, 53095 Main Road
TOWN CLERK Q P.O.Box 1179
REGISTRAR OF VITAL STATISTICS •
Southold,New York 11971
MARRIAGE OFFICER ` 4° ?TM • / Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER ®I ,1" 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. 3716-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KAMMER
Mailing Address 1 C/O JOHN D. STRODE
Mailing Address 2 633 EAST MAIN STREET
City St Zip RIVERHEAD NY 11901-0000
Property Address 1 GRATHWOHL ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-298-4503
Tax Map No. section 117.00 block 4 lot 5.000
Cross Street NEW SUFFOLK AVENUE
Issue Date: 11/03/97 Judith T. Terry
Southold Town Clerk
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(TOWN SEAL)
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V..
OFFICE OF THE TOWN CLERK COW % 22
Town of Southold ea t_ Application
Judith T. Terry, Town Clerk `
y
Town Hall, 53095 Main Road .. ) $10.00 - Residential
P. O. Box 1179 � r ii �' $25.00 - Non-Residential
Southold, New York 11971 O0 ,�`�
Telephone `er a/ N`a
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
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OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
9
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DATE 1
OWNER NAME: OlititMELIZ
OWNER MAILING ADDRESS: (NSO c-11.2-063
ENgt .1k) 1I/Q (C.?aI
OWNER PROPERTY ADDRESS: 36•7. 1(
/ 6-4 4-7-Lc()a h tfq.
OWNER TELEPHONE N MBER: 6_16) )"v—ct'S d 3
TAX MAP NO. : Section Block Lot
CROSS STREET: G4,e,(16,00 c' f& c -k4 -
TYPE
VT OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing W
esidential - 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.)
friAVALraf6/ Q
��. ' is na;''re 6 Applican
RECEIVED BY:
Town Clerk's Office
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DATE: -
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