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OFFICE OF THE TOWN CLERK
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TOWN OF SOUTHOLD �� �C�lj Application No. /421 T
ELIZABETH A.NEVIJ.i.F,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
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SOUTHOLD,NEWYORK11971 *., $25.00 - Non-Residential
Telephone 40 4t Y'a
(516) 765-1801
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
I
DATE 4. , ..if , if j
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OWNER NAME: eft l\Iafte\ 44S4-4016
OWNER MAILING ADDRESS: .\ S+ra rel Avayw-e.
" trelg-. , NNi 11530
OWNER PROPERTY ADDRESS: 345 C A. r ,i.a.cit, bNve ,
Ke,A\ v4. I N.f 1\cksa
OWNER TELEPHONE NUMBER: (51(0 $'fl - 0407
TAX MAP NO. : Section /Q(, Block 5 Lot -5-
CROSS
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 7 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.)
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srS..n. / / _
e of Applicant
RECEIVED BY71921113)
Town lerk's Office
DATE: (L( 0)
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