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JUDITH T. TERRY , ; Town Hall, 53095 Main Road
TOWN CLERK O P.O.P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICEROr/
Fax (516) 765-1823
iit Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3147-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner CLANCY, PAUL AND MAUREEN
Mailing Address 1 P. O. BOX 5110
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 225 BURGUNDY COURT
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4136
Tax Map No. section G61.00 block ---3 lot 3.012
Cross Street CHABLIS PATH
Date Of Last Pump Out 0/00/00
Issue Date: 11/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ',�FFUiL
Town of Southold O��S_ CQG_ • Application No. / V7
u�u. ..'4SI
Judith T. Terry, Town Clerk „ s s, y.
Town Hall, 53095 Main Road $10.00 - Residential L��
P. O. Box 1179 can if
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��.-'S� 3.3..,,;,..,::: $25.00 - Non-Residential
Southold, New York 11971 O _ O� ��s
Telephone -_</1 ,ild V; '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
' OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / . '
Fee $ 10: 00
DATE November 16 , 1993
OWNER NAME: Paul & Maureen Clancy
OWNER MAILING ADDRESS: P . 0 . Box 540 Southold , N . Y . 11971
OWNER PROPERTY ADDRESS: 225 Burgundy Ct . Southold , N . Y . 11971
OWNER TELEPHONE NUMBER: ( 516 ) 765-4136
TAX MAP NO. : Section 51 Block 3 Lot 3 . 12
CROSS STREET: Chablis Path
TYPE OF SYSTEM: Septic Tank T • New V Existing
CesspoolNew V Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
• LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approx!matoly,, to building and -cic:sest -road.) ,
AL44 A144;1
Ailk .• /1U'
Signature .W"�plicant
RECEIVED BY: - /d, -
Town Clerk's ffice
DATE: // —/ e-- 9
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