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JUDITH T.TERRY G'L��; Town Hall, 53095 Main Road
TOWN CLERK c ;.c P.O. Box 1179
Southold,New York 11971
REGISTRAR,OF VITAL STATISTICS O
MARRIAGE OFFICER 0�111 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER Ol * +as" Fax
(516) 765-1800
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. 3693-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SULAHIAN, JOYCE L.
Mailing Address 1 P. O. BOX 302
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 11125 PECONIC BAY BLVD.
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8612
Tax Map No. section 144.00 block 3 lot 17.000
Cross Street BAY AVENUE/MARLENE LANE
Issue Date: 9/26/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3IFD(,t��' ��
Town of Southold , < 1 CQG=� Application No.`J �✓
Judith T. Terry, Town Clerk 0„µ.•' V ,
Town Hall 53095 Main Road ) $10.00 - Residential
P. O. Box 1179 cr3 `, `` $25.00 - Non-Residential
Southold, New York 11971 O , o ��`
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Telephone ��
(516) 765-1801 Ql ��
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. - 0
Fee
$ /4 • '
DATE 24 September 1997
OWNER NAME: Joyce L. Sulahian
OWNER MAILING ADDRESS: P.O.Box 302
Mattituck, NY 11952
• OWNER,.PROPERTY- ADDRESS-: ---- 11125- Peconic Bay. Blvd.__
Mattituck, NY 11952
OWNER TELEPHONE NUMBER: (516) 298-8612; (212) 986-2246
TAX MAP NO.: Section J%' .o O Block 03. 00 Lot D/' • DOD
CROSS STREET: between Bay Avenue and Marlene Lane
TYPE OF SYSTEM: Septic Tank .New Existing
Cesspool New Existing Loef
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
RECEIVED BY:
Town Clerk's Office • '
DATE: -
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