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JUDITH T.TERRY ��I1 /,• "'` ` ; Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS `` ' 0 Southold,New York 11971
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Fax(516)765-1823
MARRIAGE OFFICER � ��� 11
RECORDS MANAGEMENT OFFICER �Qz23
,111 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. 3337-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PRIETO, RICHARD
Mailing Address 1 P. O. BOX 206
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2650 MINNEHAHA BLVD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1311
Tax Map No. section 87.00 block 3 lot 45.001
Cross Street OPECHEE AVENUE
Issue Date: 5/18/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold �® CQ Application No. 537
Judith T. Terry, Town Clerk �` w„ /
Town Hall, 53095 Main Road < $10.00 - Residential
P. O. Box 1179 cry - ��` $25.00 - Non-Residential
Southold, New York 11971
Telephone,( , `i�# "
(516) 765-1801at
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE //7
,OWNER NAME: �1.16A-- �
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OWNER MAILING ADDRESS: P, ZC7
) (3, f rk 11 '7, 7/
OWNER PROPERTY ADDRESS: ,9(65'0 / 7 4/2P -4q1:6_, l-U
X04 11 a frt NY 11971
OWNER TELEPHONE NUMBER: 7015--
TAX
701 TAX MAP NO. : Section ' Block Lot
CROSS STREET:
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.)
/AL- ) et:Uth .
Si nature of Applicant
J
RECEIVEDI
BY: L
o n Clerk's Office
DATE:
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