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JUDITH T.TERRY ` ® F $f - Town Hall,53095 Main Road
TOWN CLERK ,, :' P.O.Box 1179
C 0 ,� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS \� �1 Fax(516)765-1823
MARRIAGE OFFICER ��
RECORDS MANAGEMENT OFFICER %--:691 1 ial' Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER •0°.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3421-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PHILLIPS, GWENN
Mailing Address 1 4050 DELMAR DRIVE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 4050 DELMAR DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-9426
Tax Map No. section 125.00 block 4 lot 20.000
Cross Street EMMA DRIVE
Issue Date: 12/15/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �calFOU( '- a U
4.
Town of Southold , 0�� e,',,--- Application No.3 /�
Judith T. Terry, Town Clerk , - y:�
Town Hall, 53095 Main Road •'— .G $10.00 - Residential i.�
P. O. Box 1179 en ', ,-. i�;' $25.00 - Non-Residential
Southold, New York 11971 Oft O, . 4
Telephone _�j * ' ''�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE / / 06-
OWNER NAME: C.-------w-C�JV ,Gz."l ,6-JS
OWNER MAILING ADDRESS: L3"6 �e�� �j�/ Gf2
7 i-- 4 // 76r
9
OWNER PROPERTY ADDRESS: 6
OWNER TELEPHONE NUMBER: 6-1tox"qIS q "To2, (p
TAX MAP NO. : Section �� Block y Lot .. ,
1-10
, . -CROSS STREET: Er" 40/<1.1 V-e---
TYPE ;OF SY,ST.EM-: -See .
"
- -----------
-New xisting
- Cess.00l New - isting
'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.)
Al • de 4 _
ignature of Applicant
RECEIVED- BY; . - _
: : ;
'Town -ClerkOffice '-•
DATE: _-_, i; - - . - . - __--_- -- - __ -_ .- -- -- - • .. _ .
•
. T.,. APR 1 '1974'4'"''''—. ,
, • I ' E -f A. D, REF, Q"�0
•
.--.. The -swage disposal end water supply
• full ties for this location have been
inspec ed /by this department and
andd-found ,
•,to be s;tisPaotory ;z42 . ve:k V
11� i . -
Chief of General Engineering • -
- -
-,,. . ,- Services , ,
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