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ELIZABETH A. NEVILLE � .ok : Town Hall, 53095 Main Road
TOWN CLERK ; y = P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �'�$ Southold, New York 11971
OFFICER �� y O�,�1 Fax (631) 765-6145
MARRIAGE
RECORDS MANAGEMENT OFFICER �_�491 4:2/
��� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER sisg1'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4051-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner HEARD, PETER AND DAWN
Mailing Address 1 P. O. BOX 356
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 970 KENNEY'S ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-765-9282
Tax Map No. section 59.00 block 3 lot 17.004
Cross Street NORTH ROAD
Issue Date: 10/12/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE WN OFSOUTHOLDE &%%�FF�(K`,OG Applifation No. I/6
ELIZABETH A.NEVILLE,TOWN CLERK8g $10.00 - Residential
P.O.BOX 1179 ttz ��
SOUTHOLD,NEW YORK 11971 $25.00 - Non-Residential
Telephone *,l
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O .a°
DATE _10- 2 - 00
OWNER NAME:-.RAV 4 —}kox A
OWNER MAILING ADDRESS: --P0- 8 eytk 354
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OWNER PROPERTY ADDRESS: '370 n 5 ��•
53‘.- \d 'M \1971
OWNER TELEPHONE NUMBER: &3I- 165 -
TAX MAP NO. : Section 55. 0 0 Block 3 Lot /7. 00
CROSS STREET: War`
TYPE OF SYSTEM: Septic Tank 7 New X Existing
Cesspool New X Existing
Residential A/ 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
MAHTAJ
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