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JUDITH T.TERRY � _4 yl\ Town Hall, 53095 Main Road
TOWN CLERK ; y 2 ; P.O. Box 1179
�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS G
MARRIAGE OFFICER �� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ��o.� * *a„„'1�� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3520-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FALZON, SOLANGE M.L.
Mailing Address 1 P. O. BOX 344
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1205 POINT PLEASANT ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5991
Tax Map No. section 114.00 block 1 lot 4.000
Cross Street WESTPHALIA ROAD
Issue Date: 10/02/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK • Fa it
Town of Southold �� CQ� Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ,.`,. <,;,+ } $10.00 - Residential_
P. 0. Box 1179 u' $25.00 - Non-Residential
Southold, New York 11971 O
Telephone1.,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Selit(44&40/0 my.6
OWNER NAME: SO1.(1h1Ge M . FAL2oN
OWNER MAILING ADDRESS: (2oS Pb1 Peelad C R0 OA.
r.® . BOX 34Q, hatcgtu!! , NewYiUt 11(1f2
OWNER PROPERTY ADDRESS :
Seufte crA/diatom
OWNER TELEPHONE NUMBER: 51.6 - bq S • 5qq f
TAX MAP NO. : Section 1 fit Block I Lot
CROSS STREET: 14/<4h ek Rd '
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New (Existin )CResidtiaNon-Residential
.....rte--
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 • F_ •
gnature of1/4A licant
RECEIVED BY:
Town Clerk's Office
DATE:
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