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JUDITH T.TERRY ` TTown Hall,53095 Main Road
TOWN CLERK g P.O.Box 1179
,�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS •
MARRIAGE OFFICER � 4 ie Fax(516)765-1823
RECORDS MANAGEMENT OFFICER : f V„... 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. 3314-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FLEMING, PAUL AND MARY
Mailing Address 1 6485 PITTSFORD-PALMYRA ROAD
Mailing Address 2
City St Zip FAIRPORT NY 14450-0000
Property Address 1 35675 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 716-223-4976
Tax Map No. section 19.00 block 2 lot 10.000
Cross Street TERRY LANE
Issue Date: 3/14/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
tOlor
S_? •
OFFICE OF T.HE TOWN CLERK ,c�VFF�(��'-
Town of Southold C'
� '�, Application No. J3-�
Judith T. Terry, Town Clerk v
Town Hall, 53095 Main Road g =4„.. I $10.00 - Residential
P. O. Box 1179 z• $25.00 - Non-Residential
Southold, New York 11971
Telephone !42t41 I���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE M A AC I.{ 8 /fO
OWNER NAME: P(4 V 1.- 1)1 (r y I L'>m J A/(r
OWNER MAILING ADDRESS: 10 /7185- P .S /614-r Y Roiew
Ff IA Po kr" , Al.Y. /4(ii5-0
OWNER PROPERTY ADDRESS: f `�,5� M'175( £D
o ►2 i,'Ni` ivy', // 9i7
OWNER TELEPHONE NUMBER: (7J 6) -2 ZS- ? ? 'I ‘
TAX MAP NO. : Section WO p- U /q Block o c)- Lot 0/0
CROSS STREET: rt-RR ' LAN r
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool fr New Existing X
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.)
79, .,.x,
Signature of pplicant
RECEIVED BY: •
Town Clerk's Office
•
DATE:
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