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JUDITH T.TERRY 1�0 • Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER *` tiw � ,1� Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER �►���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. 3725-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BORN, STEVEN
Mailing Address 1 LEEWARD DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 770 LEEWARD DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3303
Tax Map No. section 79.00 block 7 lot 40.002
Cross Street
Issue Date: 11/24/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICEv OF THE TOWN CLERK „c31HU.�'=
Town of Southold Q eV-% Application No.57aC-
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 w $25.00 - Non-Residential
Southold, New York 11971
Telephone _Q( `1►�
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 312-5
Fee $ 1v . OC-D
DATE l\( 6
OWNER NAME: I� ( 6 ir
OWNER MAILING ADDRESS: r(- W Ato v q •
OWNER PROPERTY ADDRESS: _ -
OWNER TELEPHONE NUMBER: '7 S - J 3 6
TAX MAP NO. : Section 5 7, d/6 ?Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New 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.)
• / Signature of Applican
RECEIVED BY:
TownRgaBVEDffice
DATE:
N 0 V i !b 1997
South id Town Mark
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