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JUDITH T. TERRY : L ; Town Hall, 53095 Main Road
TOWN CLERK v rrZ P.O. Box 1179
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• Southold, New York 11971
REGISTRAR OF VITAL STATISTICSV® Fax Fax (516) 765-1823
MARRIAGE OFFICER oj/� O/� Telephone (516) 765 1801
RECORDS MANAGEMENT OFFICER O1
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. 3270-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner GATZ, PETER AND JENNIFER
Mailing Address 1 P. O. BOX 1735
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3115 REEVE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-734-4171
Tax Map No. section 99.00 block 3 lot 4.018
Cross Street SOUNDVIEW AVENUE
Issue Date: 10/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFA ICE,NOF THE TOWN CLERK S�FFO� '� ���
x Town of Southold ��% ..�QG'` Application N'J
Judith T. Terry, Town Clerk . s "z '. x. y •
~ ;• " ° > - �G I $10.00 - Residential
- Town Hall, 53095 Main Road � �,,.� �,�, -
P. O. Box 1179 cn a;: ' � rt `' $25.00 - Non-Residential
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Southold, New York 11971 O ,.- , '-''
Telephone _ .� 4 �1
(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: C� C azc n i Cur elQ17OWNER
MAILING ADDRESS: --PO 6 —1 J
Irna \-"\-4-\3C V NY. 1 9 -Q._
OWNER PROPERTY ADDRESS: 0 t5 VO Off. ROLA
mot--)t-11-k-i-u c.K , 1 @ c�
OWNER TELEPHONE NUMBER: 1a+ Lf 1 ,
TAX MAP NO. : Section q CI Block 3 Lot `°'tl e 0 g
CROSS STREET: (3,Un !J\�� ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New V 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.)
O E 1
C\ur\ir\ 6,,.
Signat+ e of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: /(9 / 0<'&.
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