HomeMy WebLinkAboutBraverman, Michael ,%s�FFool,
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ELIZABETH A.NEVILLE ����`Z`� O4 Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 'W 171Southold,New York 11971
MARRIAGE OFFICER : O ' ' 0 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER \_.4 0.i Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER = 0'� � ��� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 V or Non-Residential @ $25 Application No.7 2 z Y
Permit No. 4`Ra l
Owner Name C�tZ-. \
Owner Mailing Address 1-{ Z5-S- (1) Z3&L2t ' *
LcO ( t
Owner Property Address :8 /
6 , 94 Te-el
�tt-o-uo l\, _ i V;\--i {
Owner Telephone No. 2-1 2- ci Zt{—1(.0�-3
Tax Map No: Section Block I. Lot I , ' lJ
Cross Street r_-Plc& P-r- �O
Please check each that applies: New Construction
Alteration to Exist System t
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 ap oval.)
itkisii4t): 9-L'uv\Al&-j 1 Ot8 10
Signature of Applicant Date
Received by:
X71 6 , 5-
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/16/03 Receipt#: 1456
Transaction(s): Subtotal
1 Septic Permit- Operation - Resid. $10.00
Check#: 1456 Total Paid: $10.00
Name: Braverman, Michael & Mark Stefurak
2855 Cedar Beach Rd
Southold, NY 11971
Clerk ID: LINDAC Internal ID:82908