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JUDITH T.TERRY ` ` Town Hall,53095 Main Road
TOWN CLERK �r P.O.Box 1179
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pa.ti T, ,r 4T '� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :` Fax(516)765-1823
MARRIAGE OFFICER �, ® i�1
RECORDS MANAGEMENT OFFICER g" EE1 V>,8 Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,000.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3247-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GIFFORD, J. ROYAL AND VIRGINIA
Mailing Address 1 P. O. BOX 352
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1515 MINNEHAHA BLVD.
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3946
Tax Map No. section 87.00 block 3 lot 50.000
Cross Street OPECHEE ROAD
Issue Date: 9/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �3�FFO
Town of Southold , �� �QG Application No. 2 '1
7
Judith T. Terry, Town Clerk , ;'�; . . �►.�
Town Hall, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 cf3 ' y'i }aNi `� $25.00 - Non-Residential
Southold, New York 11971 4 '0���,
Telephone 'i y F'o°
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
O
Fee $
DATE 0 ,9- 3 -_�
OWNER NAME: J . 70y:1(
OWNER MAILING ADDRESS: /?O 3 )‹.
(-/-3 lid? ( 97/
OWNER PROPERTY ADDRESS: ���� S in lPt,4 3(w)
OWNER TELEPHONE NUMBER: -- 3 3 4
TAX MAP NO. : Section E7 Block 3 Lot
CROSS STREET:
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.)
SignatureApplicant
-' RECEIVED BY:
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Town Clerk's Office
DATE:
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MAP OF PROPERTY .Y • :GUARANTEED TO THE SOU,T HOLD ►
SURVEYED FOR
,� -• • . . .SAVINGS BANK i THE TITLE
�: : .. .. • GUARANTEE COMPANY •
�r • ' AS SURVEYED OCT'70,19a5SOJTHO�D
. SUFFOLK CO., t .Y. • - _I . VAN _UYLiSON -
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RENSSELAER G. TERRY, Jr., •
LICENSED LAND 51JRVEYORS -
ATTORNEY •• AT - LAWG►zEENUR;NY, ---
_ SOUTHOLD, N. Y. '