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ELIZABETH A.NEVILLE t�h`Z® V.,�; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O Fax(516) 765-1823
MARRIAGE OFFICER � ®�/ Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER ;- ®1 '1�
FREEDOM OF INFORMATION OFFICER /����
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3800-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DEY, ARTHUR
Mailing Address 1 4745 NORTH BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4745 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4129
Tax Map No. section 79.00 block 3 lot 17.000
Cross Street SHIPS DRIVE
Issue Date: 7/15/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF TLS.TOWN CLERK CO Mit
TOWN OF SOUTHOLD c CSG Application No. Cd d
ELIZABETH A.NEVILLE,TOWN CLERK �N $10.00 - Residential c/
P.O.BOX 1179 cr
SOUTHOLD,NEW YORK 11971 �� $25.00 - Non-Residential
•
• - Telephone 0 Jig V:01
(516) 765-1801
= ( TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE e ' 1S-P
OWNER NAME: /143 . -bet
OWNER MAILING ADDRESS: tp445 pow 5 Nt' - Zc.
� U TAN-1 IA
OWNER PROPERTY ADDRESS: S8
OWNER TELEPHONE NUMBER:' Si to -4-4,S -4 21
TAX MAP NO. : Section -R"01 Block 3 Lot 1 79"
CROSS STREET:
TYPE OF SYSTEM: Septic Tank / New Existing V/
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.)
Signatur of Applicant
RECEIVED BY: ii6(/1/(/(--
'Town Clerk's Office
DATE: (�/�Z
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