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JUDITH T.TERRY 4V
Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
5
• r. '- � ,�� Southold,New York 11971
•REGISTRAR OF VITAL STATISTICS ' 1
MARRIAGE OFFICER =� j� ® � Telephone(516)Fax(516)765-1823
-1823
RECORDS MANAGEMENT OFFICER I *;.11.� 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. 3336-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GAGEN, FRED
Mailing Address 1 190 GILLETTE DRIVE
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 75650 MAIN ROAD
Property Address 2 (715 FRONT ST)
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1837
Tax Map No. section 48.00 block 1 lot 9.000
Cross Street 7TH & 8TH STREETS
Issue Date: 5/18/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
••
OFFICE OF THE TOWN CLERK
Town of Southold Q CQ ' Application No333,6
Judith T. Terry, Town -Clerk' .` %-%)
Town Hall,, 53095 Main Road - r= $10.00 - Residential c/
P. O. Box 1179 - vim ;' $25.00 - Non-Residential
Southold, New York 11971O _ *-$
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Telephone �j ��� e
(516) 765-1801 - -
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: L > a
OWNER MAILING ADDRESS: /// ,
- -- --- - - OWNER PROPERTY- ADDRESS:- % c� /"' / wr �L'E`'�- d
r_ /►c 4.4 �f S �i �Ad' s� �/L��,y� D/P72
OWNER TELEPHONE NUMBER: 5477
TAX MAP NO. : . Section-W atIock ( Lot 7
CROSS STREET: e5/' 7/
TYPE OF SYSTEM:• Septic Tank New Existing
Cesspool New Existing
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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Signat re of...A cant
RECEIVED BY: - -
Town Clerk's Office
DATE: -