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JUDITH T.TERRY Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS •
MARRIAGE OFFICER -0
11� Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER ® N®
I gad Fax
(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. 3461-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner TARPEY, MARTIN
Mailing Address 1 714 BAY AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 714 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5911.7
Tax Map No. section 143.00 block 4 lot 3.000
Cross Street ROUTE 25
Issue Date: 5/06/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c,VFFOur:- (/ `
Town1Qf Southold �� CVO=\ Application No. 5 76
Judith T�`,'Terry, Town Clerk .` y�1
Town Hell, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 cn .`
$25.00 - Non-Residential
Southold, New York 11971 c ' .$
Telephone -Ta: i
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 A00 .
DATE s oZ Cita
OWNER NAME: W Z+ 11,3 \ ‘. (.1P-6,‘"/
OWNER MAILING ADDRESS: 1 I 4 I t0•2-
OWNER PROPERTY --ADDRESS: 5i°cr`vQ-
OWNER TELEPHONE NUMBER: -1 - 5S q
TAX MAP NO. : Section / 4---1 9 Block Lot 3
CROSS STREET: -- - ---- :-\--t 00N-c—
TYPE OF SYSTEM:- -=Septic= Tank-`:\• '•: "-- - -New Existing
Cesspool f New Existing
i
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.)
Sig -ture Applica
RECEIVED BY: tie , ,
-
- -• ,wnccClerk's Office ••
DATE.:.., •. -67 ,:3 -/S�
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