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JUDITH T.TERRY ������ y< Town Hall, 53095 Main Road
TOWN CLERK ; y - P.O. Box 1179
.y. Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ` I Fax(516) 765-1823
MARRIAGE OFFICER �� O�'���
RECORDS MANAGEMENT OFFICER : 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. 3446-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner POTTGEN, JOSEPH AND JACQUELINE
Mailing Address 1 550 BLUE MARLIN DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 550 BLUE MARLIN DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5517
Tax Map No. section 57.00 block 1 lot 27.000
Cross Street DOLPHIN DRIVE
Issue Date: 3/14/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
J
OFFICE` OF THE TOWN CLERK ����F�(�.�'-
, ' Town of Southold , & CQG Application No.-33VA,
Judith T. Terry, Town Clerk y /
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 tri - - • *Z" $25.00 - Non-Residential
Southold, New York 11971 O �0*.$
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Telephone I Y►
(516) 765-1801
' TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE �7
OWNER NAME: y /tom : „ _ G `
OWNER MAILING ADDRESS: cOrTh'''N"
OWNER_ PROPERTY _ADDRESVV-1 01(3((-)
OWNER TELEPHONE NUM : 47PRO
TAX MAP N • Section Bloc Lot
CROSS STREET:\ tfLL
TYPE OF SYSTEM: . Septic, Tank ., : New Existing
Cesspool V 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.)
• pj4
Sign.t e o1�App •,
04
RECEIVED BY:
_ , Town ,Clerk's Office •;'
DATE:
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