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JUDITH T. TERRY
® Town Hall, 53095 Main Road -
P.O. Box 1179
TOWN CLERK $
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971 .
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Fax (516) 765-1823
MARRIAGE OFFICER ®/y�® �®�,�! Fax
(516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1925-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHRIEFER, CLIFFORD
Mailing Address 1 145 FAWN LANE
Mailing Address 2
City St Zip CUTCHOUGE NY 11935-0000
Property Address 1 145 FAWN LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5307
Tax Map No. section 103.00 block 4 lot 23.000
Cross Street BEEBE AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Ic\ WFOL4- - /
Town of Southold � C� ' Application No. ` 7
Judith T. Terry, Town Clerk .` t J+< $10.00 - Residential
Town Hall, 53095 Main Road a k %; 1 -
P. O. Box 1179 �tf ' _ $25.00 - Non-Residential
Southold, New York 11971 4 ®; `
Telephone o( '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /P.,o 0
DATE 6./45
OWNER NAME: a '4c/ 6i-i��e�t
OWNER MAILING ADDRESS: Fa )- hcvu-c__
f) /CIO c/,rye_ /19 3_5
OWNER PROPERTY ADDRESS:. ,S'C ,4,
OWNER TELEPHONE NUMBER: 7, V ,.-73.7
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TAX MAP NO. : Section /� 3 Block 17/ Lot Q3
CROSS STREET: /�JPe /?� (jr-JD
TYPE, OF_SYSTEM:- --Septic Tank- - New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0170 v}- ICS 67a
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.)
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/ VSignature of App i nt
RECEIVED BY: , "(J( _ _.
own le'rk's Office
DATE: < S � ��
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