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ELIZABETH A.NEVILLE Town Hall,53095 Main Road
TOWN CLERK o P.O.Box 1179
h Southold,New York 11971
REGISTRAR.OF VITAL STATISTICS
MARRIAGE OFFICER ,f, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �Q! �a® Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4251-R Residential x Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner TORELLI, JOSEPH
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Mailing Address 1 79 SUMMIT RD
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Mailing Address 2
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City St Zip PORT WASHINGTON NY 11050-0000
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Property Address 1 1385 OLD SHIPYARD LANE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 516-883-8772
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Tax Map No. section 640.00 block 500 lot 27.000
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Cross Street FOUNDERS PATH
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Issue Date: 5/17/04 �abeth . Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE =`1` OGZ� Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
H Z Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS . Af
MARRIAGE OFFICER vD Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER O'f �a southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 f or Non-Residential @$25 Application No.
Permit No.
Owner Name J496eyok d
Owner Mailing Address -°t SLA I W or—
Por r—Wc--) � ,��, JAJ J v
Owner Property Address
Owner Telephone No. X 66 J'9-7-
Tax Map No: Section Block Lot Z�
Cross Street r-1--
Please
-1"Please check each that applies: New Construction
Alteration to Existing System
Residential � 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 submit copy of survey with SCHD approval.)
Signature of Applicant Date
Received by: �`
19 607
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