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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER �p ���' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 1 ` 6- ,f
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. 3304-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CAFFCA, RUBY
Mailing Address 1 BOX 113
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 275 LAUREL AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3470
Tax Map No. section 56.00 block 2 lot 7.003
Cross Street MAIN ROAD
Issue Date: 2/07/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OF4ICE OF THE TOWN CLERK C��FFO(,'�'-
Town of Southold C ,3d
OG-� Application No.
Judith T. Terry, Town Clerk .` ., y •
Town Hall, 53095 Main Road ;< $10.00 - Residential �-
P. O. Box 1179 cryM, 4' h�i ;' $25.00 - Non-Residential
Southold, New York 11971 O'`Telephone
Telephone 0,( Ar �'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for _ __
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE // _ Flo - 9y
OWNER NAME: 6-4/CP6/9 Ru 11\1
OWNER MAILING ADDRESS: � y /. 2IV/-, L30 1( l3
(L -6 )N Al. y /I4'7/
-7S
OWNER PROPERTY ADDRESS: •urtie/ ,yo 190 y I \3
600-- --k0At, v //Q7!
OWNER TELEPHONE NUMBER: 6-76 >
TAX MAP NO. : Section 67.47 Block a Lot - 3
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool )( New Existing )4--
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.)
Si ,feature c f' J, plicant
A�,�`�/
RECEIVED BY:
Town Clerk's Office
DATE:
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