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JUDITH T.TERRY �� _ Town Hall, 53095 Main Road
TOWN CLERK ; y _ P.O.Box 1179
frrSouthold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ?fh ap� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER '.( `1► �,1.,1Telephone(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. 3466-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BOWDEN, ELOISE
Mailing Address 1 210 WESTVIEW DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 210 WESTVIEW DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4576
Tax Map No. section 139.00 block 1 lot 11 .000
Cross Street BROWERS ROAD
Issue Date: 5/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i ���
OFFI E-`OF THE TOWN CLERK c,�FFOC,r#'- z /
6
Town of Southold � e'QG,� Application No.�J
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road $10.00 - Residential /0, et
P. O. Box 1179 v' � $25.00 - Non-Residential
Southold, New York 11971 4 ���`�
Telephone( O d
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 5 9,6
OWNER NAME: r�. L d / 15 CA)
OWNER MAILING ADDRESS: =1) 0 kieS *--/-v/euJ t i
129irc'c•�
OWNER PROPERTY ADDRESS : a_./G) ��`7G
CP-Tr/7-0 c_„/fC,
OWNER TELEPHONE NUMBER: i6 c2 d f s '26
TAX MAP NO. : Section /3 I Block 1 Lot /11
CROSS STREET: i" 6 UJ ,&rs Rd )
TYPE OF SYSTEM:- Septic Tank I New Existing
Cesspool I New Existing K
Residential 7 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.)
6 Le,t.✓
Signature of Applicant
RECEIVED BY: -
Town Clerk's Office
0-DATE:
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