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JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK : ® I P.O. Box 1179
� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = ,
Fax (516) 765-1823
MARRIAGE OFFICER ==.!�® a ��1' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER --
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FREEDOM OF INFORMATION OFFICER �l
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3231-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BROWN, EDNA A.
Mailing Address 1 BOX 61
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 7005 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0122
Tax Map No. section 31 .00 block 1 lot 3.000
Cross Street GILLETTE DRIVE
Issue Date: 8/01/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 1COMA'�'-
Town of Southold - CQG Application
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Judith T. Terry, Town Clerkspy .
Town Hall, 53095 Main Road .a :< $10.00 — Residential
P. O. Box 1179 Mi '. .`• $25.00 - Non-Residential
Southold, New York 11971 40;
Telephone _ .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ \O
DATE 1P,46*
OWNER NAME:
OWNER MAILING ADDRESS: job 'OA
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OWNER PROPERTY ADDRESS: O OLS r,
OWNER TELEPHONE NUMBER: — CS \
TAX MAP NO. : Section L2/ Block ( Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
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.)
\*cS13j..92v-.... Q A.
Sig ture of Applicant
RECEIVED BY:
T erk's Office
DATE: 7/#97-
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