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ELIZABETH A.NEVILLE �� yd\ Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
ti Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS v'
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER "'/ *a0,i� Telephone (631) 765 1800
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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. 4199-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name of Owner HARBORVIEW HOMES INC
Mailing Address 1 1706 COUNTY RD 35, SUITE 2
Mailing Address 2
City St Zip SOUTHAMPTON NY 11968-0000
Property Address 1 5905 WESTPHALIA ROAD
Property Address 2
City St zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-287-0772
Tax Map No. section 113.00 block 14 lot 1.000
Cross Street COX NECK ROAD
Issue Date: 4/16/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ��FO ., //
TOWN OF SOUTHOLD Al� �COIj Application No. `7 ��
EsLIZABETHA.NEVILLE,TOWNCLERK $10.00 - Residential V
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 $;' $25.00 - Non-Residential
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Telephone '0 lid 0 i'.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: 4/146-v gf AA- ec ‘..1irAc-
OWNER MAILING ADDRESS: /764 Co-24_4( 0 35 ,e- 2-
_cen,11,1:-.-7/7",i A)y PiCi
OWNER PROPERTY ADDRESS: -� - CLA o✓e--
5F7QS Lklo .-4.Q,4. reorL-
OWNER TELEPHONE NUMBER: (0 3/ a--S?-- 671t-
TAX MAP NO. : Section 113 . 00 Block /(/ Lot 1, O Oo
CROSS STREET: C a te-.4 Ir _ le ,
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.)
S-19/1/ /SCc, Li 4-� PF04
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S'r• : ,€ .f Applicant
RECEIVED BY:
Town Clerk's Office
DATE: