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JUDITH T.TERRY � x Town Hall,53095 Main Road
TOWN CLERK colg +_ P.O.Box 1179
y ' Southold,New York 11971
REGISTRAR OF VITAL STATISTICS •
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MARRIAGE OFFICER / Fax(516)765-1823
RECORDS MANAGEMENT OFFICER `= ®, i osil.' Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,.so'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3344-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GELLLMAN, MARTIN & FLORENCE
Mailing Address 1 BOX 256
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1475 MEDAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5370
Tax Map No. section 113.00 block 9 lot 5.000
Cross Street HOWARD AVENUE
Issue Date: 5/26/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S\FFM. -
Town of Southold � CQ ' Application No. 3 3 `-/s/
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road • -< $10.00 - Residential
P. O. Box 1179 cn • - ;I $25.00 - Non-Residential
Southold, New York 11971 � ••'`,
Telephone 0,( 44 �o "
(516) •765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE j•
OWNER NAME: iqi W, k1 ND fcoiL(CC
OWNER MAILING ADDRESS: cO k v140 -
�(""L`�uG(Ci
OWNER PROPERTY ADDRESS: � Re--okry /66i1/4-COC-
OWNER
TELEPHONE NUMBER: jjj(o— 1-' ' " 37
TAX MAP NO. : Section I 2 Block 7 Lot --s
CROSS STREET.: i_(A) irltb- A-0'6
TYPE OF SYSTEM: , ,Septic,,Tank , , V 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 roa,.
41 4
40,4
7 — Signature of Afplicant
•
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RECEIVED BY:
Town ,Cler.k!s, Office
DATE: _
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