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JUDITH T.TERRY ®� ?'t Town Hall, 53095 Main Road
TOWN CLERK ` _ $ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
411 � Southold,New York 11971
MARRIAGE OFFICER
w . Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER 411 l *‘1:81e6 Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER 0111
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3510-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FISCHER, DANIEL L.
Mailing Address 1 38785 MAIN ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 38785 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3868
Tax Map No. section 15.00 block 8 lot 1 .001
Cross Street RYDER FARM ROAD
Issue Date: 9/06/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK isFO v
Town of Southold IL, Application No. �
Judith T. Terry, Town Clerk ‘
Town Hall 53095 Main Road ' $10.00 - Residential_
P. O. Box 1179 U' ez " fin ;' $25.00 - Non-Residential
Southold, New York 11971
Telephone ( Ii
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL'S
d o '-v}. -Piu ei-, Wti1®u-r- t f .
Operation Permit No.
Fee $
II �
DA T E`'d(4 NE 5 TO)
OWNER NAME: :::7) .5-e44-c--R._ --1)A-NIEL. L—
OWNER MAILING ADDRESS: �3G'rS Mrt1hi 1vk-12
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OWNER
1T OWNER PROPERTY- ADDRESS : __
OWNER TELEPHONE NUMBER: 'Z-3 3 S 68
TAX MAP NO. : Section /5 Block 0 Lot 7
CROSS ST RE ETTy c fu&r",. 'R>'
TYPE OF SYSTEM: Septic Tank New_ Existing
R n
Cesspool ✓ New Existing .Y$ eQ 41.49I9)3
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
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A,
Sknature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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