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OFFICE OF THE TOWN CLERK
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COFO A'
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TOWN
OWNO ILLS SOUTHOLD
OWNCLERK � �O CO - Application No. 4°0.2
ELIZABETH C $10.00 Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 001 'W,��Zt $25.00 - Non-Residential
Telephone :01 , NON'”
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE -- 1..-0 —0t)
Cie-e-cet.esi-4 iez,<-1,)
OWNER NAME: /Wo...vr kre •14) Mt. *tel. t!27.
OWNER MAILING ADDRESS: 'off Six
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OWNER PROPERTY ADDRESS: )//L)' l/.rtc,4_i/y L✓ /j v�
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OWNER TELEPHONE NUMBER: 5161--/?° V'7--
,
161- -?° V(2
TAX MAP NO. : Section (01'7 Block OS' Lot 37
CROSS STREET: TotoW& 4,4.. .
TYPE OF SYSTEM: Septic Tank ( New t/ 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.)
/-rej&I
Signatur of Applicant
RECEIVED BY: (/0/14---)
Y
Tow Clerk's Office
DATE: d61
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