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JUDITH T. TERRY i Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
� ' Fax (516) 765-1823
MARRIAGE OFFICER ' •', Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER --..470 ,�
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. 3264-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CARAVANOS, S.
Mailing Address 1 195-19 39TH AVENUE
Mailing Address 2
City St Zip FLUSHING NY 11358-0000
Property Address 1 3530 STARS ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0438
Tax Map No. section 22.00 block 2 lot 24.000
Cross Street MAIN ROAD
Issue Date: 10/18/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
it -
OFFICE OF THE TOWN CLERK '
Town of Southold , � �Q ;� Application o.
Judith T. Terry, Town Clerk = ; .t41
,Town Hall, 53095 Main Road g $10.00 - Residential
P. 0. Box• 1179 cn �" $25.00 - Non-Residential
Southold, New York 11971 O *.$
Telephone 'I * `���o.'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
• DATE
OWNER NAME: c'epry,9,/y S'
OWNER MAILING ADDRESS: /9,> -/7
, 3s- �
OWNER PROPERTY ADDRESS: 3, � 3 67 5/cv.
/2Y39
OWNER TELEPHONE NUMBER: G/ 7 7 - 7 ja
TAX MAP NO. : Section c7Zd Block Q_ Lot
CROSS STREET: h/ �rdr
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.) .--
/ . .
•
Signature of Applicant
•
RECEIVED BY:
Town Clerk's Office
DATE:
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