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JUDITH T.TERRY ��_ ?'1: Town Hall, 53095 Main Road
TOWN CLERK ; y _ P.O. Box 1179
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w �� Southold,New York 11971
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REGISTRAR OF VITAL STATISTICS X47 Fax(516) 765-1823
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MARRIAGE OFFICER
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RECORDS MANAGEMENT OFFICER __!��?OI ol Fax
(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. 3532-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RIDDELL, EILEEN C.
Mailing Address 1 30 JACKSON ROAD
Mailing Address 2
City St Zip BRIARCLIFF NY 10510-2304
Property Address 1 305 BITTERSWEET LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 914-762-7926
Tax Map No. section 104.00 block 2 lot 3.000
Cross Street PINE TREE ROAD
Issue Date: 10/24/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIC;E OF- THE TOWN CLERK ' PFFD
Town of Southold �� CQ Application No ��`
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential-_
P. O. Box 1179 crs ?. . !. 7: ' •' $25.00 -
25.00 - Non-Residential
Southold, New York 11971 O �A® *rf :'i"fir ��•� -
or
Telephone 1
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 . .0‘)
DATE /0 -- /-;?
OWNER NAME: / `SCK. C
OWNER MAILING ADDRESS: 37>---1/3-d2Q2,/) ed. 421---40 .6t /1/4-
OWNER
1/4
OWNER PROPERTY ADDRESS :__u/
OWNER TELEPHONE NU .1r7
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TAX MAP NO. : Section Block Lot ,_j
V
CROSS STREET: Pi /V e e-Q_
TYPE OF SYSTEM: Septic Tank 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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