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JUDITH T. TERRY ; < Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS " �� Southold, New York 11971
MARRIAGE OFFICER +yQ ®� �, I Fax (516) 765-1823
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3189-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KERN, BARBARA
Mailing Address 1 P. O. BOX 544
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 550 GREENWAY EAST
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2406
Tax Map No. section 15.00 block 2 lot 14.000
Cross Street ROUTE 25
Issue Date: 4/05/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1
OFFICE OF THE TOWN CLERK cOFD(A-�
Town of Southold 4 + �.. CQG Application No.3)R7
Judith T. Terry, Town Clerk aµ:.. ) .�
Town Hall, 53095 Main Road a r'< ;---- $10.00 - Residential
P. O. Box 1179 u' ma -� �3i
$25.00 - Non-Residential
Southold, New York 11971
Telephone qj 1"°‘: I,•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPUCAT
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE --�1 2 Zlf y�
OWNER NAME: ic3 4-R 64-1/
OWNER MAILING ADDRESS: I9-69- ,e
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OWNER PROPERTY ADDRESS : $1.-6
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OWNER TELEPHONE NUMBER: �-3 �-
TAX MAP NO. : Section r.' Block 7 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing 7
Cesspool I/ New Existing I
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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Signature of Applicant
RECEIVED BY:
Town Jerk`s Office
DATE: , 37-3b
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