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JUDITH T. TERRY z ` Town Hall, 53095 Main Road
TOWN CLERK r P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER " tee,.
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�� Fax (516) 765-1823
* NW,"� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3186-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner L'HOMMEDIEU, HELEN
Mailing Address 1 550 SMITH ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 550 SMITH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-6627
Tax Map No. section 98.00 block 3 lot 34.001
Cross Street INDIAN NECK LANE
Issue Date: 3/16/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICI OF THE TOWN CLERK � FD(,Ir�"'
Town of Southold Off%c31_ 4, Application No. 5/ Y.(
Judith T. Terry, Town Clerk 1.
` ,.. _ -44 $10.00 - Residential
Town Hall, 53095 Main Road w.
P. O. Box 1179 c . ;`` ' Z $25.00 - Non-Residential
Southold, New York 11971 O ,.°Zt. ' . .$
Telephone *1'414—NOr
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
P i T
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
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OWNER NAME: ,�X iii\,
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OWNER MAILING ADDRESS: &-' O SM4kil
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OWNER PROPERTY nDDRESS / —
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OWNER PROPERTY�.. � /'� l.l1�LJCJ:
OWNER TELEPHONE NUMBER: < 1 It — or) `.
— ige 277
TAX MAP NO. : Sectio q Y Block 3 Lot -3 Si,
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CROSS STREET: - �c�� �� ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing >lc
Residential Non-Residential
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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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RECEIVED BY: , U.)/(--U('
Town Clerk's Office
DATE: 34 N
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