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JUDITH T.TERRY <` ^ Town Hall,53095 Main Road
TOWN CLERK „ 5" P.O.Box 1179
47'V®� ,�� Southold New York 11971
REGISTRAR OF VITAL STATISTICS �1 Fax(516)765-1823
MARRIAGE OFFICER 4 �® �l
RECORDS MANAGEMENT OFFICER : ®1 1 .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. 3349-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KEATING, JOAN M.
Mailing Address 1 34 BELDENWOOD ROAD
Mailing Address 2
City St Zip SIMSBURY CT 06070-0000
Property Address 1 9275 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6146
Tax Map No. section 118.00 block 4 lot 14.002
Cross Street BRIDGE LANE
Issue Date: 6/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE. OF, THE TOWN CLERK tccu9 O(,�- •
Town of Southold: � �Q • Application No. <-13�
Judith T. Terry, Town Clerk t �►
Town- Hall, 53095 Main Road ;< 1 $10.00 - Residential
P. O. Box 1179 cry $25.00 - Non-Residential
Southold, New York, 11971 Q $
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TelephoneQ( Arg •
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(516)" '765-1801
TOWN OF SOUTHOLD , ,
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC` TANK. or, CESSPOOL
Operation Permit No. '
•
Fee $ -
• DATEmac/ 9
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OWNER NAME: 0,9 'UT//116. ,
OWNER MAILING ADDRESS: v.=3Z .:‘3E- c,tJG411)pfJ ' �
‹Q/,19sc £'/ 7 -, CT ®G 6 70
- OWNER PROPERTY ADDRESS: 902 7 /47- 5-4o 4o/4r
Cv_ 49a )i1
OWNER ,TELEPHONE NUMBER: 476)73Sg-4/jI Ea�3� gam_ 78 5
TAX MAP NO. :' Section //8 Block" - - Lot /5/,
CROSS STREET: AM-
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TYPE .OF SYSTEM: Septic Tank New Existing -
Cesspool ✓ New Existing 1/7
Residential V 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.)
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Signature of
RECEIVED BY: -
T c's Office '
DATE:, • JUN 61995 .•
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