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JUDITH T.TERRY t
y _ � � Town Hall,53095 Main Road
TOWN CLERK -e-,.'p P.O.Box 1179
rpv 0 Southold,New York 11971
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REGISTRAR OF VITAL STATISTICS � ` �1 Fax(516)765-1823
MARRIAGE OFFICER ` 1
RECORDS MANAGEMENT OFFICER 71 V ,il. Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,•o'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3322-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CYPRUS, NICK AND NIKI
Mailing Address 1 P. O. BOX 61
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 400 EAST ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8024
Tax Map No. section 106.00 block 3 lot 2.000
Cross Street INLET DRIVE
Issue Date: 4/26/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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0F,./ICE-'0F THE TOWN CLERK IS�FFO(,���'
Town of Southold � CQ : Application Nos
Judith T. Terry, Town Clerk
Town Hall, 53095 Main- Road g $10.00 Residential
P. 0. Box 1179 u' �`' $25.00 - Non-Residential
Southold, New York 11971 O ���`�
Telephone Oj Jit IP;
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
00
Fee $ q•
DATE 10
OWNER NAME: AN
OWNER MAILING ADDRESS: f, 0 , d
OWNER PROPERTY ADDRESS: j O.0 6%,(0-
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OWNER TELEPHONE NUMBER: `Z,°N r
TAX MAP NO.: Section Lf 73 g 1 fl Block 3 Lot .2-
CROSS
CROSS STREET: ' I ve_
TYPE OF SYSTEM: Septic Tank New• Existing
Cesspool New - Existing 1/
Residential V 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 Ap licant-
RECEIVED BY:
Town Clerk's Office
DATE:
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