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JUDITH T.TERRY ►►�►_� yl Town Hall, 53095 Main Road
TOWN CLERK y = ; P.O. Box 1179
v "7 $ Southold,New York 11971
REGISTRAR.OF VITAL STATISTICS V O
yij� o� ���+ Fax(516) 765-1823
MARRIAGE OFFICER of * 'j ,,,i Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER , o
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3478-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WI NTERLI NC, HARRY
Mailing Address 1 P. O. BOX 1716
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 205 SUNNYSIDE ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5962
Tax Map No. section 63.00 block 1 lot 11.000
Cross Street HORTON'S LANE
Issue Date: 6/14/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK CORO'
Town of Southold '•, CQG Application No.31/7?
Judith T. Terry, Town Clerk �� yµ7° 4• `
Town Hall, 53095 Main Road $10.00 - Residential_
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 O ' '� �$
Telephone _ q
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 6
OWNER NAME: if /elf ZiAi
OWNER MAILING ADDRESS: P- � /365X /7/C
6' 07-7/04 AV // 97/
OWNER PROPERTY ADDRESS: ie-up • A � J .
o1FloA / N=/ // 92/
OWNER TELEPHONE NUMBER: '7C - 7-4•
• TAX MAP NO. : Section. 4?) Block / Lot
CROSS STREET: HZ / DN .5 div fi
TYPE OF SYSTEM-: Septic- Tank " New Existing
Cesspool New Existing X
Residential Non-Residential
LOCATION MAP: Musf'°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.)
41,
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gL , 44i ,% ` 14%r
Si. ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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