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JUDITH T.TERRY e ' ;
N ' , 4' .���� Town Hall,53095 Main Road
TOWN CLERK ,; ` P.O.Box 1179
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�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �� OP, ` 1 Fax(516)765-1823
MARRIAGE OFFICER =;�® ,`-� �®��•� Telephone(516)765-1800
RECORDS MANAGEMENT OFFICER 4 '
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. 3385-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BERRY, GLYNIS &
Mailing Address 1 ARIIZUMI, HIDEAKI
Mailing Address 2 111 FOURT AVENUE #2M
City St Zip NEW YORK NY 10003-0000
Property Address 1 24190 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 212-677-7898
Tax Map No. section 18.00 block 5 lot 18.005
Cross Street PLATT ROAD
Issue Date: 9/29/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK . 'c3IFp� - 3 3 �/�
-?own of Southold r _.% - C'
Jeidith T. Terry, Town Clerk rte
Q Application No.
Town Hall, 53095 Main Road u -- 7 $10.00 - Residential
P. O. Box 1179 in Y t �`' $25.00 - Non-Residential
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Southold, New York 11971 O ® ; -` r *-$
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Telephone e/ A NN� ''
(516) 765-1801
/(1 TOWN OF SOUTHOLD
\(15,q(*)
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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(ri APPLICATION
for
OPERATION PERMIT
- SEPTIC TANK or CESSPOOL
Operation Permit No. j Ng- la
Fee $
DATE NI ffr ?LS
OWNER NAME: 61yImS BeP( 4- tolectkAZLr1,w
OWNER MAILING ADDRESS: IR tou>L- 1- 2-#-1
K1tw yeqt k ( i,t,LT) 1661 o '3
OWNER PROPERTY ADDRESS: 4,j10 / in gl a-el
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OWNER TELNUMBER: ,/2-4,77. 771 5 342 j- is/ ,-
TAX MAP NO. : Section 1$ Block Jr' Lot /Z Oa S--
CROSS STREET: net# ,d apt!
TYPE OF SYSTEM: Septic Tank New g, •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.)
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Signature of Appli/14A
RECEIVED BY:
Tow �Clerk's Office
DATE:
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