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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK G=I
T P.O. Box 1 179
REGISTRAR OF VITAL STATISTICScfs Southold, New York 11971
® �- ��, Fax (516) 765-1823
MARRIAGE OFFICER
�1a® � Telephone (516) 765-1801
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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. 3175-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GOODWIN, JOHN O.
Mailing Address 1 P. O. BOX 750
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1040 LESLIE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5483
Tax Map No. section 97.00 block 9 lot 2.000
Cross Street BAY AVENUE
Issue Date: 2/10/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK \\FFO�
Town of Southold �� CQ ' Application No. � _ __
ff -
73-4
Judith T. Terry, Town Clerk ��"�
Town Hall, 53095 Main Road
-� $10.00 - Residential
P. O. Box 1179x � •`
$25.00 - Non-Residential
Southold, New York 11971 O `®• •
Telephone 4161*- -
'•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
OPERA i ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /®, �v
DATE 02`' 7-���
OWNER NAME: 3 UI V) (� G'c & ,)
OWNER MAILING ADDRESS: /040 �5/1e I C L 50( 75--e)
Cul-6k e7 dew y.ok 1t 33
OWNER PROPERTY ADDRESS : 1040 'i/e0G
6,11-040 e /Veto(psk l f'v3
OWNER TELEPHONE NUMBER: -570 - 73 51 ii
TAX MAP NO. : Section`"f► a -dBlock ` Lot
CROSS STREET: tyty
e/t(
TYPE OF SYSTEM: Septic Tank V New Existing if
Cesspool / New Existing '1
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE: