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JUDITH T.TERRY �� y< Town Hall, 53095 Main Road
TOWN CLERK t N2 P.O. Box 1179
v. t Southold;New York 11971
REGISTRAR OF VITAL STATISTICS :- Fax(516) 765-1823
MARRIAGE OFFICER �4. i, Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER - Jg[ * �.
FREEDOM OF INFORMATION OFFICER
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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. 3499-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MAYNE, KATHERINE
Mailing Address 1 860 BAYBERRY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 860 BAYBERRY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6526
Tax Map No. section 118.00 block 1 lot 15.001
Cross Street BRIDGE LANE
Issue Date: 8/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF `ICE OF THE TOWN CLERK cOFO(,rC�=
'
Town of Southold �� , .•. G ,•, Application No. Y�f'
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road , -� I $10.00 - Residential
P. O. Box 1179 'Rs, `' $25.00 - Non-Residential
Southold, New York 11971 OLO " �0�,���`
Telephone J * �►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
Fee $
DATE g'7.,5-7
OWNER NAME: K�-I-Gi��-,vz e� N,.
OWNER MAILING ADDRESS: (p o � L�2 / 1 (.. 121 A
OWNER PROPERTY ADDRESS: d v-Q.--
OWNER TELEPHONE NUMBER: !) 7( _ 7-- 1 to
TAX MAP NO. : Section //? Block / Lot /57 /
CROSS STREET: 15 ►-`A a.
TYPE OF ,SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential X 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.)
A'1- L4 -rAff) .1!A444 _Signature of Applicarit
RECEIVED BY:
Town Clerk's Office
DATE:
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