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JUDITH T.TERRY 4f Town Hall,53095 Main Road
TOWN CLERK � � '' P.O.Box 1179
P. 1" 1 �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS , ®4 ���1�
®,` Fax(516)7654823
MARRIAGE OFFICER �� �® �®�� Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER = �� P
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. 3334-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SHALVEY, THOMAS AND ELIZABETH
Mailing Address 1 200 BAY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 200 BAY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5153
Tax Map No. section 116.00 block 2 lot 16.000
Cross Street CASE ROAD
Issue Date: 5/16/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK SWF0Cir�'- /
Town of Southold � CQ ' Application No. 3337
Judith T. Terry, Town Clerk �` s. ri
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 *z. $25.00 - Non-Residential
Southold, New York 11971
Telephone vj i `i�°
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,0 0
DATE
OWNER NAME: �1a ill-S 1- 1-11/1.6 � 7-4 014/4 l u e
OWNER MAILING ADDRESS: (700 edy qo )4-v 1e'2 z-
C`c� �`c � v � :vy Ll7.3s—
OWNER PROPERTY ADDRESS: 34-
OWNER TELEPHONE NUMBER: : /b e7-3 (-7 S75- 3
TAX MAP NO. : Section �o Block " ,-2_, Lot /6
CROSS STREET: efl- L ( ai P
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool L- 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.)
0,, 41('/ G
Signature of Applicae
RECEIVED BY:
Town Clerk's Office
DATE:
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