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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK : ® Mitz P.O. Box 1179
vs � Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = y® t� Fax (516) 765-1823
MARRIAGE OFFICER .,`' � �' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 7®J � .
FREEDOM OF INFORMATION OFFICER �ii��•
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3260-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VERWAYEN, JOSEPH J.
Mailing Address 1 P. O. BOX 1840
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0950
Property Address 1 2750 GLENN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4331
Tax Map No. section 78.00 block 2 lot 42.000
Cross Street MAIN BAYV I EW ROAD
Issue Date: 10/18/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r
c OFFICE OF THE TOWN CLERK
Town of Southold 4e • CQ - Application No:-3���Jpdith T. Terry, Town Clerk /
Town Hall, 53095 Main Road , _ -� $10.00 - Residential
P. 0. Box 1179 toi z $25.00 - Non-Residential
Southold, New York 11971 O 0��,,,
Telephone 0 44 `ge �'
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /(7 - 1/- ? I(
OWNER NAME: �/�,41 ,0, / `T. !/e ire//,q��:d
OWNER MAILING ADDRESS: /c',' 4-0. /ct./a
�O v Jr a - - o
OWNER PROPERTY ADDRESS:_ .27 rccz. G. N g_L
.<r::.v7-/-hoL.-7 i A/ X " 1 477 / `-camgso .-
OWNER TELEPHONE NUMBER: 76,, V3 3 /
TAX MAP NO. : Section c7ir Block ,2 Lot -'42,
CROSS STREET: /y/q/,/ j„ Aly, .EA;
• TYPE OF SYSTEM: Septic Tank / New Existing /
Cesspool New Existing
Residential V 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.)
Si natu a of App lic t
/-..
RECEIVED BY: •
Town Clerk's Office
DATE:
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