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JUDITH T.TERRY � �� �� • Town Hall, 53095 Main Road
TOWN CLERK ® fi ' P.O. Box 1179
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�s 4 / �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ® ',{''
MARRIAGE OFFICER 44: -v4.04' ���� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER i ®� 415'of 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. 3489-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner FONDREY, MICHAEL AND LISA
Mailing Address 1 165 SELAH LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 165 SELAH LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 106.00 block 9 lot 4.004
Cross Street COX NECK ROAD
Issue Date: 7/25/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 1c0FUL,- '-
Town of Southold e4-% Application No. '8/
Judith T. Terry, Town Clerk �� •", y:t
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 c.n $25.00 - Non-Residential
Southold, New York 119710e�`�
Telephone �.( ° ��• 'e
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
(4-""`"e4`4'1..) DATE /�®�� 2
OWNER NAME: v" ei / /47 fIU/..
OWNER MAILING ADDRESS:
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / Block Lot
CROSS STREET:
2 L
TYPE OF SYSTEM: ,Septic Tank _, ,t,/ New / Existing
Cesspool Y New i/ Existing
Residential t,/ 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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' '6natureof Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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