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JUDITH T. TERRY : : - Town Hall, 53095 Main Road
TOWN CLERK $
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REGISTRAR OF VITAL STATISTICS � - ���' Fax (516) 765 1823
MARRIAGE OFFICER 19 f::::0‘ is Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ®� ,� f .0.! _
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. 3284-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KELLY, WILLIAM / SIKORSKI, S.
Mailing Address 1 P. O. BOX 1680
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2235 BRIGANTINE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3121
Tax Map No. section 79.00 block 4 lot 62.000
Cross Street NORTH BAYV I EW ROAD
Issue Date: 11/21/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cVFD`�C''
Town of Southold QS�
• '-� Application No. `�
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
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P. O. Box 1179 .4c ° h�i `' $25.00 - Non-Residential
Southold, New York 11971 O` ''
Telephone _Ol `*Jit •,
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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 $
DATE
OWNER NAME: A. 6.1/x--&. v4/47UDgrA — b _
OWNER MAILING ADDRESS: "Fc), L
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OWNER PROPERTY ADDRESS: Z-235 1Z I O
OWNER TELEPHONE NUMBER: 7 -5/2/
TAX MAP NO. : Section 75 Block 2/ Lot ,Z
CROSS STREET: 1\k e-/ I ry
TYPE OF SYSTEM: Septic 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.)
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SI•ZWIP6 Appli m*.nt
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RECEIVED BY: /(7-/,( 7
Town Clerk's Office
DATE: /1(/ //9(.j
22-35
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