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JUDITH T. TERRY ' :' f� j _ Town Hall 53095 Main Road
TOWN CLERK ® z P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS , r 4�` Fax (516) 765-1823
MARRIAGE OFFICER ® Det$' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER �,••••ii41i1 "''
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3253-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner TORKELSEN, DORIS
Mailing Address 1 835 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 835 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-7311-7319
Tax Map No. section 103.00 block 7 lot 24.000
Cross Street MAIN ROAD
Issue Date: 9/21/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
- •
_ .. „'
FICE OF THE TOWN CLERK " 95
9I` �FF0(,r�;- _ • ��s 3
Town of Southold � • Q Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential f�
P. 0. Box 1179` $25.00 - Non-Residential
Southold, New York 11971 O` 0*/
Telephone -_••=4 * `�� '01
(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: Doris Torkelsen and others
- OWNER MAILING ADDRESS: 835 Pequash Avenue
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: Same
•
OWNER TELEPHONE NUMBER: 734-7319
TAX MAP NO. : Section 103 Block 7 Lot 24
CROSS STREET: Main Road •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New , Existing X
Residential X • 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.)
By mail
Signature of Applicant
•
RECEIVED BY: 4' e-,-
Itir;
Taal
k's Of ice
DATE: SEP 2 0 1994
Town Clerk Southold
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