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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK : ® •
P.O. Box 1179
r 'W 1$ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = V/® �� Fax (516) 765-1823
MARRIAGE OFFICER ��` Telephone (516) 765-1801
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RECORDS MANAGEMENT OFFICER — ®1 i�
FREEDOM OF INFORMATION OFFICER � �/r/���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3282-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WAGNER, HOWARD
Mailing Address 1 P. O. BOX 975
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 510 LEGION AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4710
Tax Map No. section 142.00 block 2 lot 9.000
- Cross Street PACIFIC STREET
Issue Date: 11/21/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK TOVFD�CG1-2-Ye2
-
Town of Southold Q Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - $10.00 - Residential
P. 0. Box 1179 cr3 ;`w hzi �' $25.00 - Non-Residential
Southold, New York 11971
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Telephone (j ‘tt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE / Yi ei41-1, -
OWNER NAME: HO PCER,D L" AG NI
OWNER MAILING ADDRESS: Bo x 97-5-
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OWNER PROPERTY ADDRESS: s'/ o LE-Gip N AVE
Ti Y ) c-i< tY 1 G 9sa-
OWNER TELEPHONE NUMBER: C.S//1 o29'$- 1/7/0
TAX MAP NO. : Section 42 3 ff 7 Block / 2/a Lot o2--
CROSS STREET: eazy ',
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.)
Si gnaturepplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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