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ELIZABETH A.NEVILLE ' G# •
Town Hall,53095 Main Road
TOWN CLERK O - P.O. Box 1179
ti Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ` Fax(631) 765-6145
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RECORDS MANAGEMENT OFFICER : �Ql 0�i� Telephone (631) 765-1800
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FREEDOM OF INFORMATION OFFICER .0° southoldtown.northfork.net
OFFICE OF TH TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT`
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4228-R Residential x Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner LONG ISLAND HOME ILDERS INC
Mailing Address 1 30 BELLMORE ROAD
mailing Address 2
City St Zip EAST MEADOW NY 11554-0000
PrDperty Address 1 485 SUTTON PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
owner Telephone No. 516-735-9029
Tax Map No. section 33.00 block 5 lot 6.000
Cross Street TASKER LANE
Issue Date: 1/28/04 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE �� ;G.y�; Town Hall, 53095 Main Road
TOWN CLERK ; p P.O. Box 1179
h Z $ Southold, New York 11971
REGtSTRAR OF VITAL STATISTICS k .y.
MARRIAGE OFFICER a 'F 1� Fax(631) 765,6145-
RECORDS MANAGEMENT OFFICER ���f0 •',i•� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER = '/ I �� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 for Non-Residential @ $25 Application No. a 2-5(
Permit No.
Owner Name (c.,e-rih G'vai' /c�h TSLk�� Uc' -2 l'�v�cae,-s
Owner Mailing Address 30 13 e(6 /R„( F._ 3 riy (cii,,. 7 3-47
Owner Property Address >5 S c Ytc". /0 4 G,-e,en pGe--T* ci''
Owner Telephone No. 57 G-- 7 '3 9f GJ
Tax Map No: Section 33 Block Lot 6
Cross Street 7-0,--S ,ke r
Please check each that applies: New Construction
Alteration to Existing System
Residential 1/ Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give nortlfarrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
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Signature of Applic.--' Date
Received by: