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JUDITH T.TERRY � _ ya Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
r � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :s
RECORDS MANAGEMENT OFFICER ®y Fax (516) 765-1823
MARRIAGE OFFICER ®°` ®i��06� Telephone(516) 765-1800
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FREEDOM OF INFORMATION OFFICER , ,00
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3482-R Residential X Non-Residential
Fee $ •10.00 New Existing X
Name Of Owner NELSON, JOHN AND DIANE
Mailing Address 1 1355 KENNYS ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1355 KENNYS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4116
Tax Map No. section 59.00 block 7 lot 18.000
Cross Street NORTH ROAD
Issue Date: 6/25/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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bI FICE •OF THE TOWN CLERK •COFfU( -
Town of Southold �Q Q CQ Application No. (�).-•
Judith T. Terry, Town Clerk �� 4"'k :; qb
Town Hall, 53095 Main Road $10.00 - Residential
u
P. O. Box 1179 ' $25.00 - Non-Residential
Southold, New York 11971 �•'�`�
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ft,
DATE
OWNER NAME: 1-db rJ A . NPl-ws-v) AkID
OWNER MAILING ADDRESS: )353-- 4<enelneilie
OWNER PROPERTY _ADDRESS : , 2,f2x.y.„1/4
OWNER TELEPHONE NUMBER: ( & ) 749-C- Atffig
TAX MAP NO. : Section L.S-9 Block 7 Lot IR
CROSS STREET: 24B)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential I 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
1 C
7,-,p�cii i 0N) c,- c s co(-- IN) -re., 0,4 1 '- pC 1. v e ee
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