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JUDITH T.TERRY J 1I ' Town Hall,53095 Main Road
TOWN CLERK ® s � ` <
� c� .; _-�: ������ �� t P.O.Box 1179
• ' r 1,% Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �: 4 �1 Fax(516)765-1823
MARRIAGE OFFICER ® i
RECORDS MANAGEMENT OFFICER = `1:1 4 1%;..i. 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. 3340-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BERGLUND, AUDREY
Mailing Address 1 P. O. BOX 1501
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3400 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5651
Tax Map No. section 55.00 block 5 lot 5.000
Cross Street NORTH ROAD
Issue Date: 5/19/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�\WFO(,r�'-
Town THE
Southold , 0�� •. CDG ' Application No. 33 YO.
Judith T. Terry, Town Clerk . '` , y
Town Hall, 53095 Main Road ~ ,-_, ,- 1 $10.00 - Residential ,/
• P. 0. Box 1179 cn - - $25.00 - Non-Residential
Southold, New York 11971 O Fre• " ."
Telephone "TO Ad Orr
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for RECEIVED
OPERAT ION PERMIT MAY 19 1995
SEPTIC TANK or CESSPOOL Southoizd ®very Cie
rk
Operation Permit No. ••
Fee $ 10000
DATE os-111161.5-
OWNER
II q,JOWNER NAME: Auiy JLN d
OWNER MAILING ADDRESS: P. O , 30 L 150
St.t+ fd) NY1tq '7f
OWNER PROPERTY ADDRESS : 3W OO 1(3v gcrs AVNu
Som® Id, , (5`i' 1 (Q7 !
OWNER TELEPHONE NUMBER: f S2 ) 745-5-051
TAX MAP NO. : Section SC Block S Lot 5
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool t/ New Existing t/
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.)
426E-
Si ature o Applicant
RECEIVED BY: ‘.---------7":/).,\V)
Town stlerk's ffice
DATE: --� Ili J6
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