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JUDITH T.TERRY � Town Hall,53095 Main Road
TOWN CLERK k ' g P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS 4. �� Southold,New York 11971
Fax(516)765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER `.4 viol.', 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. 3376-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RICCIARDI, JUDY AND MICHAEL
Mailing Address 1 970 GIN LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 970 GIN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2222
Tax Map No. section 88.00 block 3 lot 12.000
Cross Street MAIN BAYVIEW ROAD
Issue Date: 8/22/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OR THE TOWN CLERK \IFFO�
Town of Southold , ��� = Application No.3 3 76
Judith T. Terry, Town Clerk CQ :\
Town Hall, 53095 Main Road ' $10.00 - Residential
P. 0. Box. 1179 u' ' Zi $25.00 - Non-Residential
Southold, New York 11971 OO '`�
Telephone Y► '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE gb/ /fs
OWNER NAME: `J tidy VI1 �ChMG'' ! Ce 1�1�1_lJ
OWNER MAILING ADDRESS: (3-7/1 �l� LR1rV f'
OWNER PROPERTY ADDRESS: d ' - -
OWNER TELEPHONE NUMBER: 7o el?). 2.
TAX MAP NO. : Section g g Block 3 Lot J
CROSS STREET: i fr,e Pl./
TYPE OF SYSTEM:- ' Septic: Tank ',- - New Existing
Cesspool I/ New- Existing
Residential I" 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!, 1/dA4-el ; I
Signature 'of Applicant
RECEIVED BY: - - -
- , - Town Clerk's Office
DATE:
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