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JUDITH
� Town Hall, 53095 Main Road
JUDITH T. TERRY �,s�
TOWN CLERK ® _ i ", ; P.O. Box 1179
VB
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS I. Fax (516) 765-1823
MARRIAGE OFFICER er ry'1, ®41. 1P,"
FREEDOM
Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER -_�®,�
�< atr/N0!/I h
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. 3230-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WHITE, PEGGY
Mailing Address 1 P. O. BOX 25
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 805 ORCHARD STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6463
Tax Map No. section 117.00 block 5 lot 40.000
Cross Street FIRST/SECOND STREETS
Issue Date: 8/01/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
rs
OFFICE OF THE TOWN CLERK c.3\\FFD(,r�
Town of Southold • CQG' Application No. 3
Judith T. Terry, Town Clerk 1'0
Town Hall, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 cn 4< � `'
� �.� .�f.f '� � $25.00 - Non-Residential
Southold, New York 11971 O4117, �O�,'`
Telephone ; 1, ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE Qic) Li t lqq�-
c7
OWNER NAME: (J-DLAtte,p0___
OWNER MAILING ADDRESS: (-) 0 OAC
n e uD S0Gc-01 HRS--.
OWNER PROPERTY ADDRESS: tql
,(1ecoCoiK 10 CI 91q
OWNER TELEPHONE NUMBER: S — (.4
TAX MAP NO. : Section ( f Block 5 Lot
CROSS STREET: e con d C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential c 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.)
(1-j_AkV-
Sli4nkture of Applicant
RECEIVED BY:(-,7/g C r�i�i
TownpIerk's Office
DATE: 7/c>7/9 --
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