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4 JUDITH T.TERRY �� y< Town Hall, 53095 Main Road
TOWN CLERK N Z -P.O. Box 1179
%)-® T Southold,New York 11971
REGISTRAR OF VITAL STATISTICS • Fax(516) 765-1823
MARRIAGE OFFICER ��Q a�� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER
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. 3479-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner NORTH SEA ASSOCIATES
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Mailing Address 1 P. O. BOX 312
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 630 NORTH SEA DRIVE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 516-765-1262
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Tax Map No. section 54.00 block 5 lot 16.000
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Cross Street KENNY'S ROAD
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Issue Date: 6/17/96 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
MJF-,FICE OF THE TOWN CLERK � 7
Town of Southold ���� ��QG Application No.- _`/1
o.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< $10.00 - Residential
P. 0. Box 1179 $25.00 - Non-Residential
Southold, New York 11971
Telephone0(
(516) 765-1801
TOWN ,OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: Po,2.rl-t Sevi cscs
OWNER MAILING ADDRESS: I�D-t- 3IZ-
j 43v r� La A ccs
OWNER PROPERTY ADDRESS; 4 3 9 w
OWNER TELEPHONE NUMBER: 7& f- -O-OL-
TAX
Zb L-TAX MAP NO. : Section S L( Block Lot
CROSS STREET: _
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.)
Signature of App"
pp c nt
RECEIVED BY:
Town Clerk's Office
DATE:
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