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JUDITH T. TERRY .G Town Hall, 53095 Main Road
TOWN CLERK ,zs,v T P.O. Box 1179
cls Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = �� Fax (516) 765-1823
MARRIAGE OFFICER '_ .j' �OI,'� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 7Q/ 4j i
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. 3217-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PAWLI K, MARGARET
Mailing Address 1 P. O. BOX 307
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1450 WEST MILL CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11944-0000
Owner Telephone No. 516-765-2422
Tax Map No. section 51 .00 block 6 lot 27.000
Cross Street GROVE ROAD
Issue Date: 6/23/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
iii i
O rICE OF THE TOWN CLERK 'c\ FOIL
Town of Southold Application No. 5,; ._/?
4 Town Clerk �t .- G 1
Judith T. Terry, -.. .k `/
Town Hall, 53095 Main Road ~ { ''' ''`F 7 $10.00 - Residential
P. O. Box 1179 v' V-At ' ` ` i $25.00 - Non-Residential
Southold, New York 11971 O ; 3 �w`
Telephone ®.( ��V .�
(516) 765-1801 ,'
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ,9( )O cf y
OWNER NAME: fla/ 'SGt
he 6,J /r it
OWNER MAILING ADDRESS:
po o 30 /
So- oid if 97/
OWNER PROPERTY ADDRESS: /VS-e) (A ' Th,'j/ A_pp it �/tilti.•-2
OWNER TELEPHONE NUMBER: C5 J(p -- 7br__ --2.- L-2_z— ,•
TAX MAP NO. : Section 51 Block 6 Lot a 7
CROSS STREET: 4
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.)
'2-ict-A--,q,w±. olA-A-ixe-4--:
Si nature of Applicant
RECEIVED BY: . . - �/v C
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To n Clerk's Off�ice
DATE: 6 ( (-(
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