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JUDITH T.TERRY 111 ; 14 Town Hall, 53095 Main Road
TOWN CLERK =_«� P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS0Southold,New York 11971
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MARRIAGE OFFICER � � Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER � � sel. 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. 3368-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VAN DYNE, MARTIN
Mailing Address 1 4110 NASSAU POINT ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4110 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7511 •
Tax Map No. section 111 .00 block 8 lot 3.000
Cross Street WUNNEWETA ROAD
Issue Date: 7/28/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFP'ICE'JOF THE TOWN CLERK s.�FFO�
Town of Southold , ,c31
� Application No. 336r
Judith T. Terry, Town Clerk �► .
Town Hall, 53095 Main Road a • -� I $10.00 -, Residential
P. O. Box 1179 � i �`' $25.00 - Non-Residential
Southold, New York 11971 OO Oro/
Telephone j �
(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: I/9/) d /�e_ A4r/ it)y / Rdi OWNER MAILING ADDRESS: ,rr(7 6 a
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OWNER PROPERTY ADDRESS: Sop-) €
OWNER TELEPHONE NUMBER: S-1,6 -- 78V- 7C/1 -
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TAX MAP NO. : Section 11/ Block r Lot
CROSS STREET: di6stui pit ea
TYPE OF SYSTEM: Septic Tank New Existing
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.)
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'?naQcant
RECEIVED BY: k
Town erk's Office _ - - ° -
DATE: °' „9� -
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