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JUDITH T.TERRY .• tA Town Hall, 53095 Main Road
TOWN CLERK Y%!. P.O.Box 1179
REGISTRAR OF VITAL STATISTICS � ® 1 Southold,New York 11971
MARRIAGE OFFICER
Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER : .� E23 'Volo 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. 3364-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MILLER, IRENE
Mailing Address 1 38-09 211TH STREET
Mailing Address 2
City St Zip BAYSIDE NY 11361-0000
Property Address 1 18675 PECONIC BAY BLVD.
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 718-229-3868
Tax Map No. section 126.00 block 4 lot 15.001
Cross Street BRAY AVENUE
Issue Date: 6/28/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
Q.FFICE OF THE TOWN CLERK ��FO• Ur
Town of Southold , �O� 14- Application No.
Judith T. Terry, Town Clerk - , *%:\
Town Hall, 53095 Main Road -� $10.00 - Residential
p. O. Box 1179 cni ;'
$25.00 - Non-Residential____=_
Southold, New York 11971 O *.$Telephone
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ,
DATE (p D Cl
OWNER NAME: Mk. \\
OWNER MAILING ADDRESS:( 3 %•--cJ° c2-L
SicA0 q 113 (09
OWNER PROPERTY ADDRESS:_ ��o S r1-'e_COrl lC.. Rkk--1 .
i� k 9 rt-Lt t 1 cis r'
OWNER TELEPHONE NUMBER: CM -38
TAX MAP NO. : Section //ax., Block r Lot 1
CROSS STREET:arc,
TYPE OF SYSTEM: , Septic Tank New Existing
Cesspool 47 New Existing
Residential4a-72.¢ � p 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.)
51(10\S k�.(
) Signature of Applicant
RECEIVED BY:
Town, Clerk's Office „
RED
DATE: -
JUN" 2 , 1995
ii own Clerk Soutroltlt