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JUDITH T.TERRY 1� �x, (0.� Town Hall, 53095 Main Road
TOWN095 Macfa
(§03 P.O. Box 1179
r � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER �1
v� t ® �/ Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER : �^ ‘000. Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER x... .01°
OFFICE OF THE TOWN CLERK
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3706-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VAN DUZER, CHARLES R.
Mailing Address 1 BOX 267
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1200 PARKWAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2295
Tax Map No. section 70.00 block 10 lot 44.000
Cross Street WOOD END WAY
Issue Date: 10/21/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE aF THE TOWN CLERK ��c31FFoure„•
Town of Southold a CQG ���
Application No.
Judith T. Terry, Town Clerk Vi
Town Hall, 53095 Main Road g , �=}y 'µ
=� ,r ..G $10.00 - Residential
«^ ��� .
P. O. Qox 1179 cn •. ',f ,• i ;' $25.00 - Non-Residential
Southold, New York 11971 O ' "`` 0 ��`,
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /'j l
OWNER NAME: k�
OWNER MAILING ADDRESS: , A ?L fAS,
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: �/� 7 5 02
TAX MAP NO. : Section ' 7B
L/?9 6 �- lock le) Lot VY.
CROSS STREET: 0(5 ci tA//
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1// 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.)
/
ignature of Applicant
RECEIVED BY: ��(9
Tows Office
DATE:
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