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JUDITH T.TERRY Town Hall,53095 Main Road
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TOWN CLERK � = � P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ® _ Fax(516)765-1823
MARRIAGE RECORDS MANAGEMENT OFFICER 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. 3418-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner NOYCE, PATRICK
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Mailing Address 1 P. O. BOX 52
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Mailing Address 2
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City St Zip LAUREL NY 11948-0000
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Property Address 1 420 BRAY AVENUE
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Property Address 2
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City St Zip LAUREL NY 11948-0000
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Owner Telephone No. 516-298-5027
Tax Map No. section 126.00 block 1 lot 21 .000
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Cross Street ROUTE 25
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Issue Date: 12/12/95 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
�PMCE OF THE TOWN CLERK
Z. Town of Southold 0�� CQG Application No.
a Judith T. Terry, Town Clerk
Town Hall, 5309 Nein Road $10.00 - Residential
P. O. E3'6x 1179 $25.00 - Non-Residential
Southold, New York 11971 O e
Telephoneo(
(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:
OWNER MAILING ADDRESS: ®3C 6"z
4AL�A 1.
OWNER PROPERTY ADDRESS:-
OWNER TELEPHONE NUMBER: -
TAX MAP NO. : Section t Block Lot
CROSS STREET: �� , , -
TYPE OF SYSTEM: .,Septicjank , ; New Existing
Cesspool New Existing I/
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.)
Signatur f Aftlicant
RECEIVED BY:
s- Town 'Clerkts Office
DATE: / 9 s-
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