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JUDITH T.TERRY 111
Town Hall, 53095 Main Road
TOWN CLERK c P.O. Box 1179
�t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS V O ��
MARRIAGE OFFICER �� Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER .#4®,1ist ��®di�, Telephone(516) 765-1800
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. 3674-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner AGELL, THOMAS
Mailing Address 1 5 HUNTING HILL ROAD
Mailing Address 2
City St Zip WOODBURY NY 11797-0000
Property Address 1 1285 THREE WATERS LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 416-692-4328
Tax Map No. section 15.00 block 3 lot 45.000
Cross Street NORTH SEA DRIVE
Issue Date: 8/13/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OOFFICE OF THE TOWN CLERK c0FO(A-•'•
Town of Southold CQG Application No36- 7C-{
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a • ;` ! $10.00 - Residential
p. O. , Box 1179 cn ' $25.00 - Non-Residential
Southold, New York 11971 o •_
Telephone ®( 1�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 6 /".-7/
OWNER MAILING ADDRESS: 17 i / ,XI / (5P�
!�J U 0 (16 [/ O v - / /( 7
OWNER PROPERTY ADDRESS : / � �l—` 37/'Nr- -' 7� .4/),
a /[ J & A/7
OWNER TELEPHONE NUMBER: `S'/ — G' 2'Z 3"
TAX MAP NO. : Section1 � Block _Y Lot
CROSS STREET: 2/0-1,./a/ 01'!/��
TYPE OF SYSTEM: • Septic Tank New Existing r�
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.)
/
Signatur Applica
RECEIVED BY: J� �� -
To n UClerk s Office
DATE: if
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