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JUDITH T. TERRY zTown Hall, 53095 Main Road
TOWN CLERK : p r-rr P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = V s �� Fax (516) 765-1823
MARRIAGE OFFICER � '' �® ," Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER �
FREEDOM OF INFORMATION OFFICER =�� � r,���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3161-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MURCHECK, CLAIRE
Mailing Address 1 6370 SKUNK LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 6370 SKUNK LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5262
Tax Map No. section 104.00 block 5 lot 3.001
Cross Street HAYWATERS DRIVE
Issue Date: 1/07/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c,VFFO(,(-...=
Town of Southold �% , <- ea -- Application No. /6/'
Judith T. Terry, Town Clerk % `' 3 &: %`• 1...-
Town Hall, 53095 Main Road c ;. `=
..4 $10.00 - Residential
P. O. Box 1179 ..,'4_,..-.:` .' ... �` $25.00 - Non-Residential -
Southold, New York 11971 O` riF _ ���`
Telephone _ 1 [ . ....
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Anne :C ar.R;
for
• OPERATION" PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -V( ,
Fee $
DATE \,, [ `t $
, OWNER NAME: C, L4- iife- /40R2... C (-(- E'( K
OWNER MAILING ADDRESS: 4 3 1 0 5 Ku N K L 4/V E-
OWNER -PROPERTY ADDRESS: ...
OWNER TELEPHONE NUMBER: g'"/L — i 1 '' — £ G
TAX MAP NO. : Section / 6 1,(. Block Lot € /
CROSS STREET: _ _...Ar�0/ �_AA —A_ ej� �,
TYPE OF SYSTEM: Septic Tank New Existing
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.)
ei.....„.„...
Signature f Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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