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JUDITH T.TERRY ��� � Town Hall, 53095 Main Road
TOWN CLERK ; +; P.O. Box 1179
°A Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ® = r:
MARRIAGE OFFICER # <, ,.,3 ®@ /' Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER 1 i► ,d' Telephone(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. 3497-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MICHELSON, SUSAN M.
Mailing Address 1 1940 MASON DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1940 MASON DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7781
Tax Map No. section 104.00 block 7 lot 16.001
Cross Street HICKORY DRIVE
Issue Date: 8/16/96 - Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK SOFO(,r =
Town of Southold --t1)
Application No,3y 7 7
Judith T. Terry, Town Clerk �� ;xr y � $10.00 - Residential c/
Town Hall, 53095 Main Road
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P. O. Box 1179 U' � :. ' �' $25.00 - Non-Residential
Southold, New York 11971 0 � r ' �� /1`,
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 ; 00
DATE E SYT
31
OWNER NAME: aGan
OWNER MAILING ADDRESS: { LC / (fl05-T)
OWNER PROPERTY ADDRESS : A
OWNER TELEPHONE NUMBER: 1-cq
TAX MAP NO. : Section /L9 ss- BI ck ! Lot` .
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CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
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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
1% 414;1(.1.7)18°.144:r
RECEIVED BY:
Town Clerk's Office
DATE: ewto
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