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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK C • P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �' Fax (516) 765-1823
MARRIAGE OFFICER �® ,t Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER =?!•®1 ,°� it
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. 3204-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SIMCIK, ELIZABETH
Mailing Address I P. O. BOX 445
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address T 205 FOUNDERS PATH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3213
Tax Map No. section 64.00 block 2 lot 31 .000
Cross Street L'HOMMEDIEU LANE
Issue Date: 5/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
ii.
OFFICE OF THE TOWN CLERK ��FD �`
,N,T.2ocr
Town of Southold OROS x•�CQ Application
Judith T. Terry, Town Clerkt. :'
Town Hall, 53095 Main Road yr4 $10.00 - Residential
P. O. Box 1179 cn *► $25.00 - Non-Residential
• Southold, New York 11971 O =O�
Telephone 16?! ��'; °
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /0/7
OWNER. NAME: 6 eff
OWNER MAILING ADDRE S: f 1
OWNER PROPERTY ADDRESS: �. ,rte.. ✓i!/,) / e '
OWNER TELEPHONE NUMBER: 7, 5 -- )3
TAX MAP NO. : Section p 'c 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.)
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714Y e I (;.1 if/iM
Sign ure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: