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JUDITH T.TERRY _ N � Town Hall,53095 Main Road
%TOWN CLERK t ; , g t P.O.Box 1179
t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1 Fax(516)765-1823
MARRIAGE OFFICER *��111
RECORDS MANAGEMENT OFFICER ®��� ED V;�d Telephone(516)765-1800 -
FREEDOM OF INFORMATION OFFICER ,•'1�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3357-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GOWEN, ROSALIE M.
Mailing Address 1 1605 CENTRAL DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 600 ZENA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9196
Tax Map No. section 106.00 block 2 lot 43.001
Cross Street SUMMIT ROAD
Issue Date: 6/20/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III •
L "'OFFICE OF THE TOWN CLERK COFULA' •
Town of Southold &,% CQG' , Application No$33 7
Judith T. Terry, Town Clerk .` • y
Town Hall, 53095 Main Road -{ $10.00 - Residential
P. O. Box 1179 to • ;' $25.00 - Non-Residential
Southold, New York 11971 ALO ,�0*-$
Telephone ( y% et
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION ,
- for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7027
OWNER NAME: eosAi m L' vj% i96(6'6 E /C,t%/!/0
OWNER MAILING ADDRESS: /6 Ceh/fjQg I b2
MA' 1i9
OWNER _PROPERTY ADDRESS: S M e' (90 '!'
V0vi
OWNER TELEPHONE NUMBER: 57(, c,291
TAX MAP NO. : Section lb (; Block o? Lot 193,/
CROSS STREET:__________`' O
1.
TYPE OF SYSTEM: . ,Septic,Tank; ;, ; New Existing ✓
3' 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.)
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Signa Si
- g ofApplicant
RECEIVED BY:
Town..Clerk's,Office "
' DATE: . - _