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. JUDITH T.TERRY �� _ j% Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
r � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :�®� ,�� Fax(516) 765-1823
MARRIAGE OFFICER a ���' Telephone (516) 765 1800
RECORDS MANAGEMENT OFFICER 1 J !
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. 3404-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VICTORIA, HENRY
Mailing Address 1 526 PULASKI STREET
Mailing Address 2
City St Zip RIVERHEAD NY 11901-0000
Property Address 1 17250 NEW SUFFOLK AVENUE
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-727-0511.9
Tax Map No. section 117.00 block 9 lot 30.000
Cross Street FIRST & MAIN STREETS
Issue Date: 10/27/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
:I S •• •�-
OFFICE OF THE TOWN CLERK �c�VFFU(,'�'-
Town of Southold' , 0�� Application N Q
Judith T. Terry, Town Clerk • CGt
Town Hall, 53095' Main Road -� $1 .00 - Residential
P. O. Box 1179 v' . $25.00 - Non-Residential
Southold, New York 11971 O ��/
Telephone at►l [ ` 'e
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10600
DATE 66cr (1,7/7
OWNER NAME: t'w`Ka ,\t TO 4
OWNER MAILING ADDRESS: 52.6, L( Tr'
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OWNER PROPERTY ADDRESS:' 1-72,50 Q SO L V-C,
SofF0AL hq5c.
OWNER TELEPHONE NUMBER: 61, q9
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TAX MAP NO. : Section It Block 0 Lot 30
• CROSS STREET: )� � � 'T s'
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.) , -
• Signature of Applicant
RECEIVED BY': - -
Town Clerk's Office -
DATE:,
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