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JUDITH T.TERRY ® *< ;; Town Hall, 53095 Main Road
TOWN CLERK t -)
„� P.O.Box 1179
•REGISTRAR OF VITAL STATISTICS •
r Southold,New York 11971
MARRIAGE OFFICER �s�, ®Q �� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER = 11 `U r' V ,,i' 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. 3384-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner NELSON, GRACE & WELLS, JOAN
Mailing Address 1 5950 NEW SUFFOLK AVENUE
Mailing Address 2
City St Zip MATTTIUCK NY 11952-0000
Property Address 1 5959 NEW SUFFOLK AVNEUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4368
8D
Tax Map No. section 115.00 block 12 lot .
Cross Street DEEP HOLE DRIVE
Issue Date: 9/21/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
L • ice,
•-OFFICE OF THE TOWN CLERK 'C0 Feu(
Town of Southold Q) CQ = Application No.
Judith T. Terry, Town Clerk
$10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 to : $25.00 - Non-Residential
Southold, New York 11971 OO yr•�`�
Telephone * '/
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE 9/? Lff-- •
OWNER NAME: CACP / ✓C/9D/1 - jog'''l /c)e
OWNER MAILING ADDRESS: 595 Q Wpu� J-7 //:
OWNER PROPERTY ADDRESS: ho ✓ P
OWNER TELEPHONE NUMBER: S-76 Z98" 1 3 C 8'71
TAX MAP NO. : SectionD Block Z- Z D c)
/ � s r O / • Lot -
CROSS STREET: cbe=c7 7 (� hr r ✓•P `� 1
TYPE OF SYSTEM: Septic Tank New ', Existing
•
Cesspool v 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.)
• / / /;2,9
Signature .f Applicant
r '
RECEIVED BY:
ow Clerk's Office
DATE: ./( q
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