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JUDITH T. PERRY Town Hall, 53095 Main Road
TOWN CLERK k c ;;*; % P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS = 1� Southold,New York 11971
MARRIAGE OFFICER 4, %). Fax(516)765-1823
RECORDS MANAGEMENT OFFICER ®1 `�j , Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER „„ ,••I'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3307-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner STARWOOD, DAVID & TAYLOR, JANE
Mailing Address 1 P. O. BOX 387
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3985 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9502
Tax Map No. section 121 .00 block 1 lot 2.000
Cross Street BERGEN AVENUE
Issue Date: 2/08/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c,3uFFO(,�' '-
Town of Sau�hold � CQG Application No.330 7
Judith T. Terry, Town Clerk �� -, y 4\
Town Hall, 53095 Main Road ! $10.00 - Residential
P. 0. Box 1179 cn tri �`- $25.00 - Non-Residential
Southold, New York 11971 O ,r ` �`�
Telephone 70 *
(516) 765-1801 '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • •
DATE .a•/Ce( QS-
OWNER NAME: t V lD STk WOOL j'A &felA44LD-
OWNER MAILING ADDRESS: P.01 SI 3 $ 7
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OWNER PROPERTY ADDRESS: 3 `Z Z 50,-t-un
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OWNER TELEPHONE NUMBER: a- 9e•-`1) co 2-
TAX MAP NO. : Section / Block / Lot 0--
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.)
Signature of pplicant
RECEIVED BY:
�2�LJ
�¢darnel k's Offic
DATE: FEB 81995
Town Clerk 6outlrbl+
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