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JUDITH T.TERRY ,���� 4 Town Hall, 53095 Main Road
TOWN CLERK c ; P.O. Box 1179
1,i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax (516) 765-1823
MARRIAGE OFFICER V ri# 0000
RECORDS MANAGEMENT OFFICER ®d „if 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. 3430-R Residential X Non-Residential
Fee $ 10.00 New Existing X
_ Name Of _Owner . . , SA.NTACROCE, HENRY F.
Mailing Address 1 P. O. BOX 1686
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 310 RICHMOND ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-0039
Tax Map No. section 51 .00 block 6 lot 13.000
Cross Street COUNTY ROAD 48
Issue Date: 2/02/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,-- „
\OFFICE OF THE TOWN CLERK sc0F1J(,r°#=
Town of Southold �� CQG=� Application No.� 36
Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road . $10.00 - Residential
P. O. Box 1179 hi ;' $25.00 - Non-Residential
Southold, New York 11971 Oft 0*-$
Telephone
''f0.i f ' 'o
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 1-1eni3 F• e
OWNER MAILING ADDRESS: ,60x /6?'
.co„...6l,.d //y
OWNER PROPERTY ADDRESS: 7/0- .
•
OWNER TELEPHONE NUMBER: 765-- av32
TAX MAP NO. : Section ,� / Block rP Lot I3
. CROSS STREET: Cve4.--►17
TYPE, OF SYSTEM: ='Se'ptiC-Ta'nk - ". 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.)
•
Si nature of Applicant
RECEIVED BY:4
To n Cler 's Office
DATE: //3-
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