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JUDITH T. TERRY . Town Hall, 53095 Main Road
TOWN CLERK ® T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICSit Southold, New York 11971
MARRIAGE OFFICER ® r
Fax (516) 765-1823
5111 0.°
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3183-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SEIFERT, J. ALICE
Mailing Address 1 360 DOGWOOD LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3360 DOGWOOD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-9373
Tax Map No. section 54.00 block 8 lot 2.000
Cross Street KENNYS ROAD
Issue Date: 3/10/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
ie
OFFICE OF THE TOWN CLERK
Town of Southold � = CQ� Application No.3/4(f5
Judith T. Terry, Town Clerk . - 1 . y
Town Hall, 53095 Main Road � -
� $10.00 - Residential
P. O. Box 1179 v' Zi
$25.00 - Non-Residential
Southold, New York 11971
Telephone Q( 114
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ / �^
DATE rilate / 7/ /9 7
OWNER NAME: 04 -
OWNER MAILING ADDRESS: aJ , Lj� ,�%%ti 4-x-e---
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OWNER PROPERTY ADDRESS: , 6-D •
.if 1 i CSL. -22 r / 1 7/
OWNER TELEPHONE NUMBER: -5-7 �,.3 73
TAX MAP NO. : Section I/ 7 3 ner 9 Block 3-44 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing f�~
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.]
c,51 • ignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
J. ALICE SEI'rERT • 'l. 1
o"0 DOGWOOD LANE - i 5 .
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