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JUDITH T.TERRY � k ryas 4 11, Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ., �
Southold,New York 11971
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MARRIAGE OFFICER �� e ®��� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER . ®.� Ngl •a•t° Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,0.61
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3739-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RAMSAUER, KENNETH
Mailing Address 1 P. O. BOX 1428
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 900 FOX HOLLOW ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5488
Tax Map No. section 113.00 block 6 lot 22.000
Cross Street DEER PATH ROAD
Issue Date: 12/03/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK %IFNI(
Town of Southold c Application No..310:
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 8 _: .
.G $10.00 - Residential
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P. O. Box 1179 tr: '&t z' $25.00 - Non-Residential
Southold, New York 11971
Telephone *alid �� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 -
DATE - `'(
OWNER NAME: kjeN et- 4 Cwry54.-tc6--X,
OWNER MAILING ADDRESS: 0• eQ )c /42Y
OWNER PROPERTY ADDRESS: 'j' Fo y 43/(O1 ) 1oa_cI
/114-p i qu,ac NY" // q/ 6 oZ
OWNER TELEPHONE NUMBER: 5/6 -
TAX MAP NO. : Section 1 / 3 Block to Lot A a
CROSS STREET: e - R-7-14
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.)
he, (
Signafu're of Applicant
RECEIVED BY:
Town Clerk's Office
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DATE:
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