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JUDITH T.TERRY 1I®� yt; Town Hall, 53095 Main Road
TOWN CLERK �y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
Southold,New York 11971
MARRIAGE OFFICER '4' X47 Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER '. 'I 1 Oroof Telephone(516) 765-1800
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. 3707-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GIESE, THOMAS
Mailing Address 1 2195 NASSAU POINT ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2195 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-4001
Tax Map No. section 104.00 block 13 lot 4.000
Cross Street
Issue Date: 10/21/97 Judith T. Terry
•
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK ,S�FFOC� =
Town of Southold �� CQApplication No.3 76. 7
G
Judith T. Terry, Town Clerk .�� �j
Town Hall, 53095 Main Road $10.00 - Residential
n
P. O. Box 1179 cry $25.00 - Non-Residential_
Southold, New York 11971 O*al ��`
Telephone *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 40,
DATE ,t 30 107
OWNER NAME: 111 arms 6l-PS Ps 9- ��z�
OWNER MAILING ADDRESS: a 1q /�'dl'.�Sac,s,� G 1 k® d
-Iz,„1/4"cie t
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: ,,jam/ (O' 734— 400 /
TAX MAP NO. : Section /a / Block /3 Lot 1/
CROSS STREET:
TYPE•OF SYSTEM: Septic Tank S 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.)
//r R
ignature of Ap licant
RECEIVED BY:
Town C erk's Office
DATE:
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