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JUDITH T.TERRY e�� Town Hall, 53095 Main Road
TOWN CLERK ` y _ P.O. Box 1179
� Southold,New York 11971
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REGISTRAR OF VITAL STATISTICS v4 O
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MARRIAGE OFFICER `O'y �� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER =�o./ jig �a0,,•' 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. 3553-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MURRAY, DANIEL W.
Mailing Address 1 735 REEVE AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 735 REEVE AVENUE
Property Address 2
City St Zip MATTITUCK NY' 11952-0000
Owner Telephone No. 516-298-6305
Tax Map No. section 114.00 block 9 lot 11 .000
Cross Street NEW SUFFOLK AVENUE
Issue Date: 11/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFIGE OF THE TOWN CLERK \FFO
Town of Southold , 0��� • CQ ,� Application No:-33-5-13Judith T. Terry, Town Clerk {; G+
Town Hall, 53095 Main Road .G $10.00 - Residential
P. O. Box 1179
� ' '' h. �' $25.00 - Non-Residential
Southold, New York 11971 O `+ �® 0
Telephone -70
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
-
Fee $ /0
DATE ////q/q6
OWNER NAME: Vit k
OWNER MAILING ADDRESS: /5 ; , ,r , I/ (J C; _
4- 1 177, K y
OWNER PROPERTY ADDRESS: 52 9s hi-/L /A/6
OWNER TELEPHONE NUMBER: 0 i I
TAX MAP NO. : Section Y. Block q Lot I/
CROSS STREET: XI67.1 a �Fc9 L !/E—,
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.)
7 y 2
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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