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JUDITH T.TERRY � � 'yam Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(516) 765-1823
MARRIAGE OFFICER . y 0
RECORDS MANAGEMENT OFFICER ."j * 4#011° 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. 3691-R Residential X Nor-Residential
Fee $ 10.00 New Existing X
Name Of Owner VOGEL, WILLIAM P.
Mailing Address 1 85 SOUTH CENTER AVENUE
Mailing Address 2
City St Zip ROCKVILLE CENTRE N,Y 11570-0000
Property Address 1 1765 VANSTON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-594-0933
Tax Map No. section 111 .00 block 6 lot 1 .000
Cross Street HAYWATERS ROAD
Issue Date: 9/18/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK CI\VHU.,'=
Town of Southold �� CQG Application No. 3 --.9/
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road :C $10.00 - Residential
P. O. Box 1179 • un �' $25.00 - Non-Residential
Southold, New York 11971 O *.$
Telephone *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $
•
DATE - Q'r
OWNER NAME: C.t'�®//�Q9Zr� / 6GeL
OWNER MAILING ADDRESS: gds ,Sova Cr-sv€ /0.4
gee-et4 Cf.4/7F,e ,v /f3-70
OWNER PROPERTY ADDRESS: /74..rvey#114/6,%___
reZo 4i,7
OWNER TELEPHONE NUMBER: ..rd 07.33 /ii _73, 4vC
TAX MAP NO. : Section /1 P Block 6 Lot
CROSS STREET: G 4!4%,e
TYPE OF SYSTEM: Septic Tank New Existing
"Cesspool t/ New Existing
Residential j 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.)
Je/e
Signature of Appli 7t
KJ
RECEIVED BY:
RE Clerk's Office
.
DATE: SEP 18 1997
Southold Town Clerk