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`W `� Town Hall, 53095 Main Road
�'® ��` P.O. Box 1179
®1 •�®��� Southold, New York 11971
JUDITH T.TERRY �.-A...woit o TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 792-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner CANEJA, SUSAN, ILDA, & MARIE
Mailing Address 1 3900 GREYSTONE AVENUE
Mailing Address 2
City St Zip RIVERDALE NY 10463-0000
Property Address 1 330 DOGWOOD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4155
Tax Map No. section 54. 00 block 8 lot 3 .000
Cross Street KENNEY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK ''-
Town of Southold = 2--7a'
® ..��;�• CQ Application No.
Judith T. Terry, Town Clerk , <x• �
Town Hall, 53095 Main Road g's- ' �. :
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