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JUDITH T.TERRY I°_ �: Town Hall, 53095 Main Road
TOWN CLERK ; y ; P.O. Box 1179
�` Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :14j)
MARRIAGE OFFICER :�#4° ���� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = .� *®til' Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,s.'
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OFFICE OF THE TOWN CLERK
TOWN OFSOUTHOLD
SOUTHOL'D WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3752-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WOZNICK, CHARLES AND ANNA
Mailing Address 1 P. O. BOX 44
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 1230 OLD ORCHARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0254
Tax Map No. section 31 .00 block 6 lot 26.000
Cross Street DOGWOOD LANE
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Issue Date: 12/31/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK %c31 0,,
Town of Southold �� CQ Application No.
Judith T. Terry, Town Clerk �� - �►
Town Hall, 53095 Main Road -< 1 $10.00 - Residential /0, J0
P. O. Box 1179 tri �`� $25.00 - Non-Residential
Southold, New York, 11971
Telephone .( 44 'NW
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(516) 765-1801
TOWN OF SOUTHOLD
, SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • •
DATE /l IC-- 97
OWNER NAME: CJ 14-r le-545 ` 3 Pc. ' ia t
OWNER MAILING ADDRESS: '/7-0. 4/
/2- 30 0 Id DreA4rd L,¢ uelr fi"Par J4 ai:3?
--OWNER PROPERTY ADDRESS: /2 3 8- 6 ld 4-wd'
OWNER TELEPHONE NUMBER: 427 OZS`-4' 174r J'3 ,5(/D ,7i4 y
TAX MAP NO. : Section 3/ Block - Lot ,24
CROSS STREET: :665 wood
TYPE OF SYSTEM: Septic Tank ' New Existing
Cesspool v" New Existing
Residential Non-Residential
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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.)
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Signatu 'e of ' pplicant
RECEIVED BY: _ -
Town Clerk's Office
DATE:
J.-V/1/g?
Old Orchard Lane
Dogwood Lane
90 feet
160 feet
Woznick Residence
1230 Old Orchard Lane
North
I`
75 feet
25 feet
35 feet
Residence of Charles and Anna Woznick
1230 Old Orchard Lane
County Tax Map 1000 Section 31
Block 6 Lot 26
Field Map # 5083 Lot 175
Cesspool Location