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JUDITH T. TERRY = z Town Hall, 53095 Main Road
RK P.O. Box 1179
REGISTRAR OTOWN
V VITAL TATISTICS Southold, New York 11971
MARRIAGE OFFICER �® • ®�' Fax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3105-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NOVICK, BARRY AND SANDRA
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Mailing Address 1 P. O. BOX 1854
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 255 FOUNDERS PATH
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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. 516-765-5276
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Tax Map No. section 64.00 block 2 lot 32.000
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Cross Street L'HOMMED I EU
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Date Of Last Pump Out 0/00/00
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Issue Date: 8/26/93 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�VFF�(,� _
Town of Southold �� CQG Application NoJxxd
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< $10.00 - Residential
P. 0. Box 1179 cra $25.00 - Non-Residential
Southold, New York 11971 O
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: ` a r✓�/ c�- z,.��/U .> ��<�r���
OWNER MAILING ADDRESS: �� �� / S
zz 7z
OWNER PROPERTY ADDRESS: '4`® �ccv�d/�,�s �d,
OWNER TELEPHONE NUMBER: '`®/�
TAX MAP NO. : Section ef-)4 j�6" —Block— cZ
CROSS STREET: /7�/ ���dc,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing (/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
\�i��JIJ)
,�(gnature of Applicant
RECEIVED BY:
Town Clerk's Office /aa' --
DATE: r'