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JUDITH T.TERRY � =�0 Gym Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
v, ri7 1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
4.9 Fax(516) 765-1823
MARRIAGE OFFICER ik �0 �
FRRECORDS EEDOM OF / Telephone(516) 765-1800
MANAGEMENT FORATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3675-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GOLDEN, CHRISTOPHER & DANIELLE
Mailing Address 1 118 WASHINGTON AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 118 WASHINGTON AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-8776
Tax Map No. section 41 .00 block 1 lot 28.000
Cross Street MIDDLETON AVENUE
Issue Date: 8/13/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK //
Town of Southold � CD Application No. b 7�
Judith T. Terry, Town Clerk `) $10.00 - Residential d�
Town Hall, 53095 Main Road 8
P. O. Box 1179 13 $25.00 - Non-Residential
Southold, New York 11971 O �l.., r,-•. �0��•',
Telephone - t ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE //0/9/9J
OWNER NAME: an, ,
OWNER MAILING ADDRESS: /// j,v4fkah //1/P,
yG, ivy . //9yy
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: -f22
TAX MAP NO. : Section y/-/-;,?(' Block Lot
CROSS STREET: m/6W4/7 /97/Z---
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
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.)
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Pool31 p7l1/2
Du5( Signature of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE: