HomeMy WebLinkAboutHollowell ELIZABETH A.NEVILLE _�® ®G'd'� Town Hall, 53095 Main Road
TOWN CLERK H P.O.Box 1179
REGISTRAR,OF VITAL STATISTICS - sh-0 Southold, New York 11971
MARRIAGE OFFICER sfi �� 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
SOUTHOLD WASTEWATER DISPOSAL PERMIT
- OPERATION PERMIT
SEPTIC TANK or CESSPOOL
operation. Permit No. 4245-R Residential x Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner HOLLOWELL, TIMOTHY
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Mailing Address 1 1280 SMITH DRIVE SOUTH
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Mailing Address 2
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City St zip SOUTHOLD NY 11971-0000
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Property Address 1 1280 SMITH DRIVE SOUTH
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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. 631-765-3037
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Tax Map No. section 76 block 3 lot 11.001
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Cross Street MAIN BAYVIEW ROAD
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issue Date: 2/13/04 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
�OFFICE OFTHE TOWN CLERK O�j�FF�vI`+O
TOWN OF SOUTHOLD Application No.
0�. lj
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
- P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 • $25.00 - Non-Residential
Telephone -
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. G'
Fee $
DATE
OWNER NAME: �D %f� L1-.o td LL
OWNER MAILING ADDRESS: Igne S/Y1/%ft _��/ �� 56,) -/�y
�v L :c�,
OWNER PROPERTY ADDRESS: 4:9,n S ! l/21 ✓GJ r
OWNER TELEPHONE NUMBER: 63
TAX MAP NO. : Section 76, 00 Block —Lot—//, D�
CROSS STREET: BVI A-lN J6A Y J/ifu) /C a
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.)
1�
Signature o Appl1 ant
RECEIVED BY:��6 -
Town Clerk's Office
DATE: � OLI n
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OLIC�ptJfJ'TYRTN,EWT OF HEALTH SERVI `B a
FOR APPROVAL OF CO;VSTRUCTION FOR ` �(
a1NGLK PAt kV ZESMUNCE ONLY Nev�$; - 1� \��
A OVED .. �— � e o
FOR NtAXMIU 1n 0r l on
Ii XPIRES THREE YEARS FROM DA APPROVAL.
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paslWle olan. .• — be YJ essed by Health De
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SEPTIC SYSTEM CROSS SECTION � �
CzLS'} i c v�-v�s v� 'd o�n s��1 Inc Ta-YJ� dF 0 / 04-
LOT: 47 4 48
MAP OF: 6005E ",EGK
FILED: NOVEMBEr< 22, Ig48 NO. 1663 GO.
51JFFOLK
5!TUAT DD 5OUTHOLD, TOWN 0= S I -r-E PLAN I
DIST. 1000 5EG. 76 5: <3 LOT 11.1 5GALE: 1 = 4pI-0II
SITE PLAN 0;-: THE G h o r les Metas
OLLOI�ILL RS I I� NG arch f .e � t:
PO.BOX 877 ,IAr'S"C2RT, NY I I q47
51-'ITH pRIVE SOUTH, 5OL'HOLV NEA—TORIC (631) 7Z7�7aa3
NOV. 10, '02
REV, NOV, 28. '02
Qev AN. 28, 103