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ELIZABETH A. NEVILLE Town Hall, 53095 Main Road
TOWN CLERK H Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK /
TOWN OF SOUTHOLD 1o1 Y1/13
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10-A./or Non-Residential @ $25 _ Application Noq
Permit No.
Owner Name 112
Owner Mailing Address /
Owner Property Address r e
Owner Telephone No. 57; _5 41We r - ! 3c~
Tax Map No: ection Block Lot
Cross Street" "
Please check each that appli s: New Construction
Alteration to Existing System
Residential V Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may 7with it copy of s SCHD royal.
Signa eofApplicant Date
Received by:
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