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JUDITH T.TERRY _ ` ' ; COGS r `;
Town Hall, 53095 Main Road
TOWN CLERK i r �� .z P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ty. " � Southold,New York 11971
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MARRIAGE OFFICER �� "'`` .a���I Fax(516) 765-1823
Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER 1 L %r„
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. 3434-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GAIPA, WALTER AND LINELL
Mailing Address 1 P. 0. BOX 247
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 360 LAKEVIEW TERRACE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-9713
Tax Map No. section 31 .00 block 9 lot 12.000
Cross Street BAY AVENUE
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Issue Date: 2/13/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cDVFFfJ 4. '-
Town of Southold �� CQG Application No. -413 g.
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road 8 $10.00 - Residential
P. O. Box 1179 to • ' *t�;' $25.00 - Non-Residential
Southold, New York 11971 Off` *-�`
Telephone _' *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 2 '
OWNER NAME: 4(414r he/ l 9C{
OWNER MAILING ADDRESS: 17O&X pfi , ,.
a Ny /Jf3
OWNER PROPERTY ADDRESS: 3( 0lceinu-‘„
Yr He(clan qy
OWNER TELEPHONE NUMBER: V-11 —
TAX
-11 --TAX MAP NO. : Section / 610 f 3 1 Block Lot Z
CROSS STREET:--- :gay- -
TYPE OF SYSTEM: Septic-Tank , - . r 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, approximate y, to building and closest road.)
404L .°11
Signatu e of Applicant •
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RECEIVED BY: � / _
r • , - Town-.Clerk's Office
DATE: /.9(9,62 -
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