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JUDITH T.TERRY 11_%* ya Town Hall, 53095 Main Road
TOWN CLERK _Go P.O. Box 1179
,�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER �� ®�t'i1�� Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER ®1 `A�,i. 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. 3393-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PETERS, WILLIAM AND JEAN
Mailing Address 1 1600 PINE TREE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1600 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-7311-5989
Tax Map No. section 98.00 block 1 lot 19.000
Cross Street SKUNK LANE
Issue Date: 10/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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EYFFICE OF THE TOWN CLERK COMA'
Town of Southold , �� CQG= -Application Nc 33 9
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road =� $10.00 - Residential
P. O. Box 1179 cr3 z' $.25700 - Non-Residential
Southold, New York 11971 4 O�'�`�
Telephone -40 �6
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: 1/4_
OWNER MAILING ADDRESS: (6k.) . P/A/ie: b/-
A(, // S
OWNER PROPERTY ADDRESS: 41Air
OWNER TELEPHONE NUMBER: 7 3 1••/ .51(499
TAX MAP NO. : Section Block - Lot
CROSS STREET: !C u &K. 1,--4
TYPE OF SYSTEM: , Septic. Tank 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.)
ighature of Applicant
/yL^�
RECEIVED BY:
•
To n erk's ,Office
DATE: •
RECEIVED .
OCT 1 s 1995 .
-fowl Clerk Southold
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