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JUDITH T. TERRY • Town Hall, 53095 Main Road
TOWN CLERK : = ►Z P.O. Box 1179
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td� � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = VO ," Fax (516) 765-1823
MARRIAGE OFFICER .j' ® ,�� Fax
(516) 765-1801
RECORDS MANAGEMENT OFFICER 7®1 .1
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. 3199-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner STARK, PAULINE
Mailing Address 1 COMRIE, NICOLE
Mailing Address 2 P. O. BOX 773
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 ' 4425 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7576
Tax Map No. section 111 .00 block 9 lot 7.000
Cross Street CARPENTER ROAD (CARRINGTON)
Issue Date: 5/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c.0HU(
Town of Southold � CQ ' Application No. Siff'
Judith T. Terry, Town Clerk ;P2
Town Flail, 53095 Main Road "` ; $10.00 - Residential
P. O. Box 1179 Fit ` ; $25.00 - Non-Residential
Southold, New York 11971 ® ® ��`
41 It Telephone j '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 'rj 9f
OWNER NAME: PROLINE SIPqRK N(C'OG,C COM tZt'F .
OWNER MAILING ADDRESS: Po • fy < 0 3
v—r oG-uL 1113s; s
OWNER PROPERTY -ADDRESS: 4-419
cu rratO E) ticto . ((6/35
OWNER TELEPHONE NUMBER: 57 - 15 4 - 1 S-7
TAX MAP NO. : Section / / / Block • Lot 7
CROSS STREET: e, ��� RC() C 4,
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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Signature
of Applicant
RECEIVED BY: AL
Town Clerk's ice
DATE: \.5.7. /9-N/
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