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JUDITH T.TERRY � � Town Hall, 53095 Main Road
TOWN CLERK gal P.O.Box 1179
•
•REGISTRAR OF VITAL STATISTICS • "V 1�, Southold,New York 11971
�� Fax(516)765-1823
MARRIAGE OFFICER -#® `e����� Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER
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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. 3424-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WRYNN, KEVIN AND JOAN
Mailing Address 1 GENERAL DELIVERY
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 635 LLOYDS LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-722-8520
Tax Map -No. section 99.00 block 3 lot 11.012
Cross Street SOUNDVIEW AVENUE
Issue Date: 1/04/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOFO(,,(' ?9' '
Town of Southold &,% CQG Application No.J / -/
Judith T. Terry, Town Clerk �� - y
Town Hall, 53095 Main Road 1 $10.00 - Residential 11 /
P. O. Box 1179 cni `' $25.00 - Non-Residential
Southold, New York 11971 O O*-$
Telephone,( �1 et RECEIVE
(516) 765-1801
TOWN OF SOUTHOLD n';
101441 Nit So flit 0
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /e /U s--®0 3 q
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Fee $ /0
DATE /72-0(-
OWNER
72- qIrOWNER NAME: A----1,1/ A,/ cf 164W
OWNER MAILING ADDRESS: .ei/E'z4-y
Ir 4-1"-r z/-11c,c , iv,/ )/ 9 S-
OWNER PROPERTY ADDRESS : 635 LLD yL.447
cy , /
empera,P-/ t vO�t K
OWNER TELEPHONE NUMBER: 71. 2 - �'�ao 41‘7- 6006
TAX MAP NO. : Section l Block 3 Lot lf. /_
CROSS STREET: uNh✓`,� V AVE-.
TYPE OF SYSTEM: Septic Tank i/ New i/ Existing
Cesspool New Existing
Residential 1✓ 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.)
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RECEIVED BY:
Town Clerk's Office
DATE:
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