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JUDITH T.TERRY �� �� Town Hall, 53095 Main Road
TOWN CLERK kP.O. Box 1179
�' °'► t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER =- ��
�®I 1� i� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER p1"1���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3718-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MEISEL, ANTHONY C.
Mailing Address 1 227 PARK AVENUE
Mailing Address 2
City St Zip HOBOKEN NJ 07030-0000 1
Property Address 1 1275 FANNING ROAD
Property Address 2
City St Zip NEW SYFFOLK NY 11956-0000
Owner Telephone No. 201-659-4491
Tax Map No. section 117.00 block 4 lot 30.000
Cross Street NEW SUFFOLK ROAD
Issue Date: 11/03/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE a?�F THE TOWN CLERK 'c�v� FO(,(�"�
Town of Southold � CQG.\ Application No.V / /6
Judith T. Terry, Town Clerk *-‘1\\
Town Hall, 53095 Main Road -� $10.00 - Residential
c31'
P. O. Box 1179 u' hi ��' $25.00 - Non-Residential
Southold, New York 11971 O : �,'`�
Telephone *a. * *O�'/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE I�
OWNER NAME: 40 C��4 Page-cS-a? —
OWNER MAILING ADDRESS: -LZ-)- r0-/k
OWNER PROPERTY ADDRESS: ft, 5- y� lilC�' Roe ` e'90-15676
F 1o0- �� 1(Q1
OWNER TELEPHONE NUMBER: z_01 - bS '- C( J t---?-31 --1-r6 0 ( Y' *-4-4
TAX MAP NO. : Section t r )-- Block C( Lot
CROSS STREET: au) Q(JEC 96a,
TYPE OF SYSTEM: Septic Tank Z . New Existing ✓
k 1
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:
Town, Clerk's Office -
DATE: -
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