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JUDITH T.TERRY � � *1: Town Hall, 53095 Main Road
TOWN CLERK y t P.O. Box 1179
i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
:°4) '1
MARRIAGE OFFICER L ,s Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER 49./ Telephone Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,,'s°
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3533-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LOSGAR, JOSEPH
Mailing Address 1 948 CENTER DRIVE
Mailing Address 2
City St Zip FRANKLIN SQUARE NY 11010-0000
Property Address 1 1525 OLD ORCHARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-437-6326
Tax Map No. section 31 .00 block 15 lot 3.000
Cross Street NORTH ROAD
Issue Date: 10/24/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'CM MFa2
Town of Southold �® } CQG Application No.Js3)
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ,' "sxx $10.00 - Residential_
P. O. Box 1179 ;5.;!•Y ` � $25.00 - Non-Residential
Southold, New York 11971 00 �i'�`
Telephone ( y1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE ®C.®7"° 2.-?:7 1976
OWNER NAME: ; L , c,,,4(z
OWNER MAILING ADDRESS: ? ' c . J)amiv
OWNER PROPERTY ADDRESS : 444 (OLP o ' G$-1q-g*
_ gterrr �`�'� k i , M y 1/ 3 9
OWNER TELEPHONE NUMBER : ,17 —6 3a 67
TAX MAP NO. : Section J l Block l ( Lot
CROSS STREET: V,gr , tr'`26
TYPE OF SYSTEM: , 'Septic''=Tank_- _ New Existing
-
Cesspool New Existing t
Residential tiff"'
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.)
ffignaturjof Applicant
RECEIVED BY:
Town Clerk's Office
DATE.:
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