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JUDITH T.TERRY ��_® ®Gyp Town Hall, 53095 Main Road
TOWN CLERK y - P.O. Box 1179
'47 � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O ►► Fax(516) 765-1823
MARRIAGE OFFICER ‘ #* .►
RECORDS MANAGEMENT OFFICER _ ®,( * �� ,',i Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER •• ,,iii
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3639-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner O'LEARY, JOSEPH
Mailing Address 1 C/O GENDOT ASSOCIATES, INC.
Mailing Address 2 P. O. BOX 847
City St Zip WADING RIVER NY 11792-0000
Property Address 1 PINE TERRACE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 22.00 block 5 lot 4.000
Cross Street WILLOW DRIVE
Issue Date: 5/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 3 P
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Town of Southold \oc��FFQ( C,D Application No: ��
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential_
P. O. Box 1179 cn {* � $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 $ •
DATE
OWNER NAME: J0.5 P/- kg/9/e)/
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OWNER MAILING ADDRESS: P2/. erY .I I �r
J, / /17
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER :
TAX MAP NO. : Section �• a- nn Block J Lot
CROSS STREET:-
TYPE OF SYSTEM: Septic' Tank New v Existing
P
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 Apprf.nt
RECEIVED BY:
. . Town Clerk's Office
DATE:
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