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JUDITH T. TERRY ; Town Hall,
TOWN CLERK : vFri P.O. Box 1179
UI ' Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
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MARRIAGE OFFICER ��� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER O ►�
FREEDOM OF INFORMATION OFFICER = �ir����
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3162-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GOELDNER, KONRAD AND DIANE
Mailing Address 1 39 CRESCENT BOW
Mailing Address 2
City St Zip RIDGE NY 11961-0000
Property Address 1 252 LAKE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-924-3074
Tax Map No. section t ;` . 1 1 block 3 lot 19.001
Cross Street GROVE DRIVE
Issue Date: 1/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK �FFU
Town of Southold �� �COp p A lication No.� /6
is A
Judith T. Terry, Town Clerk ' y �2
Town Hall, 53095 Main Road ` � w '' $10.00 - Residential c/d
P. O. Box 1179 u' �` ' ,. .` ' $25.00 - Non-Residential
Southold, New York 11971 ym
Telephone 0( ' '1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
PPL!LA
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D. 00
DATE P1.5-e gy p, /y)3
OWNER NAME: K '.- J D i' )t 8067.-7 tU L,
OWNER MAILING ADDRESS: 3 °f C'.R,L=SCEIJ oJ
g.. 1 D �� , f ,7! i i /_�
OWNER PROPERTY ADDRESS: 5 ,, LAKE Z .' il/n.
s�ct71/OL22 / nl .$ (1 //
OWNER TELEPHONE NUMBER: (5-10 9j- 3o7 /
TAX MAP NO. : Section V'1.7/1'p Block ('O Lot -3 -/r- /
- CROSS STREET: JiCOUL
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 road.)
f,/,
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: - -
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al _ _ ry 20 61-
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