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ELIZABETH A.NEVILLE �����® •y�; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O. 179��� Fax(516) 765-1823
MARRIAGE OFFICER
%• Fax t ® 'fi Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER : �®� �
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3804-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DBM CO.
Mailing Address 1 P. O. BOX 2100
Mailing Address 2
City St Zip GREENPORT NY 11911.11.-0000
Property Address '1 550 ORIOLE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-1300
Tax Map No. section 55.00 block 6 lot 15.009
Cross Street LISA DRIVE
4if 4stiga
Issue Date: 7/30/98 E zabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK `uFFO(,(�
TOWN OF SOUTHOLD , ��� CDS Application No. ®�
ELIZABETH A.NEVILLE,TOWN CLERK • 7 $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 ��' $25.00 - Non-Residential
Telephone _ 1 * ' '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT JUL 2 9 1998
SEPTIC TANK or CESSPOOL
Town Clerk Soutnolo
Operation Permit No.
Fee $ •
DATE 6i 2
OWNER NAME: ) G .
OWNER MAILING ADDRESS: P . O . ra a X a t O 0
C, gEEA) PO/2 A) / i (gc-1q
OWNER PROPERTY ADDRESS : 5.5-6 Q r . I o L L �� I Oe
OWNER TELEPHONE NUMBER: 5 I b - 4 1-1— t 3 Q O
TAX MAP NO. : Section g5 Block 6 Lot /S- f
CROSS STREET: l- l S if bg
TYPE OF SYSTEM: Septic Tank i7 New V Existing
Cesspool New Existing
Residential It, Non-Residential
LOCATIONMAP: 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.)
,
Signature of App icant
RECEIVED BY: l► A L._
To ' n Clerk's Office
DATE: [ liel(it S
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