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JUDITH T. TERRY �' Town Hall, 53095 Main Road
TOWN CLERK ® ' ae �z, P.O. Box 1179
s la �� Southold, New York 11971
REGISTRAR OF VITAL.STATISTICS V® �� Fax (516) 765-1823
MARRIAGE OFFICER � " �® �� Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER =_ Bis
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. 3302-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner STRAUSS, MARC & KERN, COLETTE
Mailing Address 1 1095 CUSTER AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1095 CUSTER AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-0031
Tax Map No. section 70.00 block 9 lot 16.000
Cross Street BREISTADT COURT
Issue Date: 1/20/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFiCE,OF THE TOWN CLERK o�FFO`�C
Town of Southold 1 ���� Q�_� Application No. -5-3e2'2•--'Judith T. Terry, Town Clerk . - ‘,/Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u2 $25.00 - Non-Residential
Southold, New York 11971 0 ��,`,
Telephone ? , � •
(516) 765-1801
TOWN- OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 111711s-
OWNER NAME:
MARC STRAUSS AND COLETTE KERN
OWNER MAILING ADDRESS: 1095 Custer Avenue
Southold, 11971
OWNER PROPERTY ADDRESS: Sno, es 1.1ooye.
OWNER TELEPHONE NUMBER: 76r-oo31
TAX MAP NO. : Section 7o Block 9 Lot 1G
CROSS STREET: Bve.isk,A
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing v"
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 Applicant
RECIIVED
RECEIVED BY: JAN Q 1995
I01104effiCkuttail Office
_ DATE:
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