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JUDITH T.TERRY �� Town Hall, 53095 Main Road
TOWN CLERK 3 c ; P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O O��, Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER - ®.( * j d1 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. 3437-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SCHMIDT, VIRGINIA AND OTHERS
Mailing Address 1 C/O CHARLES SCHMIDT
Mailing Address 2 200 ROGERS ROAD
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 200 ROGERS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2501 Od
Tax Map No. section 66.00 block 2 lot
Cross Street ORCHARD & HIPPODROME
Issue Date: 2/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK "
o OS��FO�C A lication No. 3�
Town of S Southold & OG , pp
Judith T. Terry, Town Clerk �� *4-1 $10.00 - Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 � $25.00 - Non-Residential
Southold, New York 11971 "�`
Telephone :�� [ �% 0'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $ 10, Q0
DATE
5t �-4Ly#v t(A,usr,(y ,� tier ;¢ 00/A161- Sc ��r
OWNER NAME �ekbegL5S £2/#,,' r
OWNER MAILING ADDRESS: „zoa S £0,9z1
oe,t771O4-4. /J..14 1/97/
OWNER PROPERTY ADDRESS: 2.0l! k64-5 f
�,-//04," A14-14) / J(
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section f/A-P jle72 Block 9 Lot C
CROSS STREET: mcw4 g by,,,aPR,osfLfg
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing 1"
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.)
;z4.2c.. .-6--6/4s.
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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