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JUDITH T.TERRY ►� O'11\ Town Hall, 53095 Main Road
•-i TOWN CLERK ; _ P.O. Box 1179
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47$�� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER `.y , Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER = .` � �000 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. 3539-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BOERGESSON, CARL P.
Mailing Address 1 1860 HIAWATHA PATH
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1860 HIAWATHA PATH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3308
Tax Map No. section 78.00 block 3 lot 42.002
Cross Street NAKOMIS ROAD
Issue Date: 11/06/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
4 „il�yljy IV // IIS II
OFFICE OF THE TOWN CLERK COF1J
Tern of Southold �® y , �Q :� Application No.3S3
Judith T. Terry, Town Clerk y
Town Hall 53095 Main Road 8 3Z-.;' "JxM, 1 $10.00 - Residential
P. O. Box 1179 u' a; ''" P iii �' $25.00 — Non-Residential
Southold, New York 11971
Telephoned
(516) 765-1801
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $M •
DATE i/�/— 94
OWNER NAME: Cor P. -6/J � �^ =� °5 C.) `
-31
OWNER MAILING ADDRESS: / AO.J4,. i)U )7cu
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:C5(Ia)•7 336
TAX MAP NO. : Section 47g ?g' Block le- Lot
CROSS STREET: �, Gtj „ d- !( 1 4
1
TYPE OF SYSTEM: Septic Tank 17 New Existing
Cesspool I/ New Existing _.._
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.)
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Signature f Rpplica t l -�
RECEIVED BY: ,`t 01
• Town Clerk's Of ice
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