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JUDITH T.TERRY `�� . Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
REGISTRAR OF VITAL STATISTICS � Southold,New York 11971
MARRIAGE OFFICER '•.-°' � Fax(516)765-1823
RECORDS MANAGEMENT OFFICER .1 *)...4 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. 3379-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SHAPIRO, BARRY
Mailing Address 1 P. O. BOX 2511
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 625 WOOD LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-7311-2628
Tax Map No. section 86.00 block 6 lot 7.000
Cross Street INDIAN NECK LANE
Issue Date: 9/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1
OFFICE OF THE TOWN CLERK c3IFUtfr
Town of Southold t4%_\ Application No. 7
6/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u' t ;'
$25.00 - Non-Residential
Southold, New York 11971
Telephone : Iiren
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE -2,0- , C,
OWNER NAME: f'AR PL( SH-AP/R0
OWNER MAILING ADDRESS: po Go( z54
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OWNER PROPERTY ADDRESS: 62,5 W 00P LAN&
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OWNER TELEPHONE NUMBER: Tj((o - 734 26 2V
TAX MAP NO. : Section Block Lot 7
CROSS STREET: Nbi{.6.) VGA
TYPE OF SYSTEM: Septic Tank - = I/ 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.)
•
Sig/ ure of Applicant
RECEIVED BY: •
Town Clerk's Office
DATE:
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