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JUDITH T.TERRY ���� s M"ANA I 1 Town Hall, 53095 Main Road
TOWN CLERK ® l ` P.O. Box 1179
4,t(4
��g• Pp, �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS %® � ''old,', �/� Fax(516) 765-1823
MARRIAGE OFFICER � � ' '� ®�j��� Telephone(516) -1823 765-1800
RECORDS MANAGEMENT OFFICER = 1
FREEDOM OF INFORMATION OFFICER ,f'161
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3555-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RIOS, ARTHUR AND CATHERINE
Mailing Address 1 1000 MINNEHAHA BLVD.
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1000 MINNEHAHA BLVD.
Property Address 2
City St Zip SOUHTOLD NY 11971-0000
Owner Telephone No. 516-765-9204
Tax Map No. section 87.00 block 2 lot 7.000
Cross Street OSSEO STREET
Issue Date: 11/29/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFAG- OF THE TOWN CLERK �FFU
Town of Southold �� CQ Application No. 6
3
Judith T. Terry, Town Clerk �- f ' ' k•. '`
Town Hall, 53095 Main Road .•!. r ' " -.4 _� $10.00 Residential
P. O. Box 1179 cry ; `4.y,', ' ► $25.00 - Non-Residential
Southold, New York 11971 O�f�
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE f7Jl c1. ITL
OWNER NAME: Okr-Cee--ote 4t0-5
OWNER MAILING ADDRESS: / 0-0-0 /"(j/vn,P /q /4-
S 0Id 1) (071
OWNER PROPERTY ADDRESS: /o 11-4 6.,,op, 1, _ Igf 4) T
OWNER TELEPHONE NUMBER: 51/62 -- („ -- u
TAX MAP NO. : Section f 7 Block { Lot 7
CROSS STREET: 05_540 3/
TYPE OF SYSTEM: Septic Tank New Existing _
Cesspool V New Existing L�
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.)
i
L_
Signature of Applicant
RECEIVED BY:
TownRildiNk8ffice
DATE:
`:: ����//
N OV 2 7 1996
Southold Town Mac
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