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JUDITH T.TERRY ` ® - Town Hall,53095 Main Road
TOWN CLERK t c g P.O.Box 1179
'll Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1 Fax(516)765-1823
MARRIAGE OFFICER gt. �r2, i j11/ Telephone O 6 765-1800
RECORDS MANAGEMENT OFFICER °Q `vs' V oseP )
FREEDOM OF INFORMATION OFFICER .4
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3321-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SMITH, MARJORIE
Mailing Address 1 P. O. BOX 936
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 370 WILLIAMSBERC DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5634
Tax Map No. section 78.00 block 5 lot 9.000
Cross Street BAYV I EW ROAD
Issue Date: 4/26/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
J
OFFICE OF THE TOWN CLERK oCOFair�'-
Town of Southold Q L'
�G'; Application No. 3,v
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - $10.00 - Residential t/""
P. 0. Box 1179 1 '
Southold, New York 11971 0 . *��•
Telephone `. $25.00 - Non-Residential
0"/�,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 4/— 6...6
OWNER NAME: MARJORi ) Sh71T �I
OWNER MAILING ADDRESS: 370 in/f11la sbe Drive. (a O. B6X 934)
Suttee di N.Y6 /19'71-0/3O -
OWNER PROPERTY ADDRESS: as 'oi ve
. OWNER TELEPHONE NUMBER: s),g 5---,61C3 41
TAX MAP NO. : Section Block Lot
CROSS STREET: a, Po ad,
TYPE OF SYSTEM: Septic Tank V New Existing
Cesspool New Existing
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Residential Non-Residential
/d"OP Cc-, /@t c?ty Reb w'i-/t` / Fe6
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.)
I
Signature of Applicant
RECEIVED BY:Xii .
own Clerk's Office
DATE:
6/9.3----
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