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JUDITH T.TERRY k a '4 d Town Hall, 53095 Main Road
TOWN CLERK k e " t P.O.Box 1179
Vgilk Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ®� '�� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER � 4�.', 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. 3389-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WILSON, ROLAND
Mailing Address 1 240 SILVER COLT ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 240 SILVER COLT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5026
Tax Map No. section 95.00 block 4 lot 18.038
Cross Street COUNTY ROAD 48
Issue Date: 10/05/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OF�_�' ._' OF THE T•
OWN CLERK
Town of Southold �� CSG= Application No.
Judith 'T. Terry, Town Clerk
Town Hall, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 tn . • � � $25.00 - Non-Residential
Southold, New York 11971 OO
Telephone .( y► '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Uy
Fee $ �O •
1
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DATE � �i/ - 95-
OWNER NAME: kofaiJ W CSD
OWNER MAILING ADDRESS: a416 Sit(/e/Y- CRL7 Kd
/w//4 7 /93
OWNER PROPERTY ADDRESS:_fQ
OWNER TELEPHONE NUMBER: s--f0-.'7�4- SUa -b
TAX MAP NO. : Section �`� ° sl Lot 4
CROSS STREET:
TYPE OF SYSTEM: Septic Tank I New Existing
Cesspool New Existing n
- 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.)
Signa ure of Applicant
RECEIVED, BY:
Town. Clerk's Office
DATE: , -
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