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Town Hall, 53095 Main Road
40' P.O. Box 1179
i Southold, New York 11971
JUDITH T.TERRY 1 , "®2y
1: 1 TELEPHONE
KM CLERK ��C����� (516) 765-1801
REGISTRAR Oh VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3605-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BROWNING, JONATHAN •
Mailing Address 1 3455 LITTLE NECK ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 3455 LITTLE NECK ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6895
Tax Map No. section 103.00 block 10 lot 11 .001
Cross Street
Issue Date: 4/10/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3VFHie
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Town of Southold &,% CQ�t Application No. 36O�
Judith T. Terry, Town Clerk �� • . �.
Town Hall, 53095 Main Road < $10.00 - Residential
P. O. Box 1179 "M ;• $25.00 - Non-Residential
Southold, New York 11971
Telephone _`0144. � '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /65, 60
DATE I/ /97 7
OWNER NAME: JO /U ,9_/"-A .) r &J ,d t ,rJ
OWNER MAILING ADDRESS: g(6--,5- ,c7`71-/� 6ted
CA c o ei/ v 1/ jr3 ct --
OWNER
OWNER PROPERTY ADDRESS-:
•
OWNER TELEPHONE NUMBER: (5-*
TAX MAP NO. : Section / Block . Lot y kms-
'.i ;: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.)
• ' _ 1• V '`
Signature of plicant
RECEIVED BY: _ ,
Town' Clerk's Office
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