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ELIZABETH A.NEVILLE � '
TOWN CLERK ® " P.O. Box 1179
t Southold New York 11971
REGISTRAR OF VITAL STATISTICS V°16 `' �,
'f 's4 ' /�� Fax(516) 765-1823
MARRIAGE OFFICER ®��� Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER ® 1� �� P
FREEDOM OF INFORMATION OFFICER /' I
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3789-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MOELLER, JACQUELINE B.
Mailing Address 1 P. O. BOX 269
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 809 MAPLE LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4661
Tax Map No. section 64.00 block 1 lot 31 .000
Cross Street ROUTE 25
Issue Date: 5/13/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK • ac3VFFU(,�"
Town of Southold �� CQG Application No.-J 717
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road g .< $10.00 - Residential
P. O. Box 1179 u' - tri `' $25.00 - Non-Residential
Southold, New York 11971 OO
Telephone ( * y► ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /AO
DATE /5 90
OWNER NAME: ,7/9-eazzeZiil/z- L ,2eie//ez
OWNER MAILING ADDRESS: TO Sefxc, 6
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OWNER PROPERTY ADDRESS: 061 h9/9-PL6- LgiV�
Soa- -W, NV 1117
OWNER TELEPHONE NUMBER: 576 - 163-- / % / •
TAX MAP NO. : Section X73 cYd 9 Block , JI Lot — 3
CROSS STREET: ROj,L725 `j962/ri , auk
TYPE OF SYSTEM: Septic Tank _New Existing
Cesspool V New Existing k.,/
Residential V 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.)
C )4/82-61../6-4-_,,,
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nature of licant
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RECEIVED BY:
Town Clerk's Office
DATE:
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