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JUDITH T.TERRY �� '� `` t Town Hall 53095 Main Road
TOWN CLERK ayes ` P.O.Box 1179
` Q '�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ' 1 Fax(516)765-1823
MARRIAGE OFFICER 1
RECORDS MANAGEMENT OFFICER 41 4 /• 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. 3391-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RYAN, JANET
Mailing Address 1 BOX 286
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 46365 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3877
Tax Map No. section 63.00 block 3 lot 13.000
Cross Street LOCUST LANE
Issue Date: 10/10/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �SOFO(,(.'=
Town of Southold &,% % Application No.''3T/
Judith T. Terry, Town Clerk y:� /
Town Hall, 53095 Main Road a $10.00 - Residential V
P. O. Box 1179 tri ' %) $25.00 - Non-Residential
Southold, New York 11971 0_
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Telephone -cf®.( y O� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. ���° am,
$i l
Fee $ /O', aa 00T 6 , O
-73
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OWNER NAME: /1/11-5 , Jc'ie_/ Rya,.'.,
OWNER MAILING ADDRESS: c.) / c-72()
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OWNER PROPERTY ADDRESS: .56,5C_5 /ice (-91 RI
.56&(5% id /v / ? 7 /
OWNER TELEPHONE NUMBER: 5/6 n: 5 ,-,s' '7 7
TAX MAP NO. : Section 63 , Block "3 Lot " /3
CROSS STREET: 466(4s-7f— La...)-)e__,
TYPE OF SYSTEM: Septic Tank . New Existing
Cesspool V New Existing i '
i------.'
' Residential t/ 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 C erk's Office '
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DATE: /0 .( ' - q.�
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