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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK : ® T P.O. Box 1179
trs Southold, New York 11971
REGISTRAR OF VITAL STATISTICS V® '' Fax (516) 765-1823
MARRIAGE OFFICER ' .. .) ��' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 7®,� 1� i�
FREEDOM OF INFORMATION OFFICER =�, �i., �
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3203-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LOVELL, AMANDA NORRIS
Mailing Address 1 P. O. BOX 775
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 302 TOWN CREEK LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3658
Tax Map No. section 64.00 block 1 lot 12.000
Cross Street YOUNGS AVENUE
Issue Date: 5/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO V CJ
Town of Southold X05 >tCQ Application No. `3 a 3
Judith T. Terry, Town Clerk 4t '4"1
Town Hall, 53095 Main Road -'� $10.00 - Residential
P. O. Box 1179 Ln �f," � $25.00 - Non-Residential
Southold, New York 11971
Telephone( y ,4 to
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT V
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE _1( 9 1 -1 l LL
OWNER NAME:
OWNER MAILING ADDRESS: 6). 0 .
5 °LACo lk 1 1 `� I
OWNER PROPERTY ADDRESS: 3 O 'To LA-W\ C.`CeC ( LOvvu
e 9.91
OWNER TELEPHONE NUMBER: ( ..r-} 3 6 b
TAX MAP NO. : Section (CJ Block ( Lot fzg—_
CROSS STREET:
TYPE OF SYSTEM: Septic 'Tank i New Existing L
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.)
M5'e e be_t_ck .
Signature of App icant
RECEIVED BY:
Town Clerk's Office
ti
DATE:
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