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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = � �. .t' Fax (516) 765-1823
MARRIAGE OFFICER =_afy .�� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER — 1411
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. 3265-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SHENGOLD, MELVIN AND PAULA
Mailing Address 1 P. O. BOX 2092
Mailing Address 2
City St Zip GREENPORT NY 11911.11.-0000
Property Address 1 20 SANDY BEACH
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1234
Tax Map No. section 3.00 block 3 lot 8.000
Cross Street MANHANSETT AVENUE
Issue Date: 10/18/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OT-TICE OF THE TOWN CLERK
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Town of Southold Q C' -30Z�S�
Judith T. Terry, � =` Application No.
Town Clerk
Town Hall, 53095 Main Road g $10.00 - Residential
P. O. Box 1179 cr's h�i z $25.00 - Non-Residential
Southold, New York 11971 Oft *.$
Telephone Oj * •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE (6 —fitLgti
OWNER NAME: 01 / , 1 -If
OWNER MAILING ADDRESS: / l� ` .'.1 X90•
PLQAP-wir,-;
OWNER PROPERTY ADDRESS: A /
, /1 1./6Y
OWNER TELEPHONE NUMBER: 676 — 477
TAX MAP NO. : Section 3 Block Lot e
CROSS STREET: 1 r , . el/
TYPE OF SYSTEM: Septic Tank New Existing j
Cesspool N/ / New Existing J
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.)
Signat lie of Applicant
6
;ti RECEIVED BY:
Town Clerk's Office
DATE: