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JUDITH T.TERRY 1�1® Town Hall,53095 Main Road
TOWN CLERKcr�n P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS 0 1
MARRIAGE OFFICER Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER : 01 ED Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ���„ ,i•��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3306-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FREDERICK, DONALD
Mailing Address 1 1555 GLEN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1555 GLEN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3845
Tax Map No. section 78.00 block 1 lot 24.000
Cross Street MAIN BAYV I EW ROAD
Issue Date: 2/08/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
66 `L
OFFICE OF THE TOWN CLERK
Town of Southold Application CQG,� Application No.33 6.6
Judith T:.Terry, Town Clerk
Tail,9 53095 Main Road ;< I $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 4`
Telephone �.( * • °I
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE (9. /7�'��
OWNER NAME: p ()Aix/ • 11� ec1 eh rerti
OWNER MAILING ADDRESS: /5JS ' 64e/9 $'6027/o2, J (1F7/
OWNER PROPERTY ADDRESS: issi. GA 0
OWNER TELEPHONE NUMBER: 76 r_ I? 75
TAX MAP NO. : Section 7 Block / Lot 0/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential ,K 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-44
` - Signature of Applicant
RECEIVED BY: b(--//b0
own Clerk's Office
DATE: (9 - rl
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