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JUDITH T.TERRY � � `_��� : Town Hall, 53095 Main Road
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TOWN CLERK « 4 t P.O. Box 1179
trA e3� "4 e' Southold New York 11971
REGISTRAR OF VITAL STATISTICS ® '' t .c 11
MARRIAGE OFFICER L 4 �' �1 Fax(516) 765-1823
;�® 4 �®••• Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER � �•�
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. 3560-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner SPITZENBERC, ROBERT F. JR.
Mailing Address 1 375 ELIZABETH LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 344 TERRY COURT
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2361
Tax Map No. section 69.00 block 3 lot 6.004
Cross Street GLOVER STREET
Issue Date: 12/06/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cvFFQ(,l(�''-
Town of Southold Application, CQ.�� Application No.3 0
Judith T. Terry, Town Clerk �� " tix �fy
Town Hall 53095 Main RoadI $10.00 - Residential
P. O. Box 1179 y�t� �t . i �' $25.00 - Non-Residential
Southold, New York 11971
Telephone ®( NW
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /371 ,
Fee $ /O.00
DATE !// o
OWNER NAME: /6,6ej-7 „iPj`,,.eGvA-6e rq 'JR
OWNER MAILING ADDRESS: 37S— EAa.6� (jiw$_.
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OWNER PROPERTY ADDRESS: 30/ , ee7
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OWNER TELEPHONE NUMBER: /
TAX MAP NO. : Section 0.00 Block 3 Lot 6.005(
CROSS STREET: • g/0_E.R_ HJT.
TYPE OF SYSTEM: Septic Tan, N- Existing_
Cesspool _NIL_
W. 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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RECEIVED BY: _
Town Clerk's Office
DATE: •
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