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£JUDITH T.TERRY Town Hall, 53095 Main Road
TOWN CLERK y _ P.O. Box 1179
T �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ` 1 Fax(516) 765-1823
MARRIAGE OFFICER 40 - se
RECORDS MANAGEMENT OFFICER : l jig i s,� Telephone(516) 765-1800
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. 3464-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GODFREY, WILLA H.
Mailing Address 1 BOX 228
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 475 OYSTERPONDS LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2471
Tax Map No. section 25.00 block - 1 lot 4.000
Cross Street ROUTE 25
Issue Date: 5/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ��FF�(A.
Townof Southold �� QG Application No. 3,y____Ey
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 8 -< ` $10.00 - Residential
P. O. Box 1179 u' M ,1
$25.00 - Non-Residential
Southold, New York 11971 O " •= q-clo �o�
Telephone _ l [
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7 Z
OWNER NAME: / I t,.L/9 � , G-01)FREY
OWNER MAILING-ADDRESS: JO X Z 2�
4CAI /VT; /rVY 11L ( ?
OWNER_PROPERTY ADDRESS: I7C_ V.67FRPO curs 1 , V-E—
OR I E N i, /V \I ( 1 '1,S-7
OWNER TELEPHONE NUMBER: c-/ - - `)--47/
TAX MAP NO. : Section � Block / Lot
CROSS STREET: T E ,
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.)
Signature of Applicit T
RECEIVED BY: ,.
"Tow Clerk's Office
i
DATE: 9C
i 1
9