HomeMy WebLinkAboutManzi Homes Inc (10) •
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ELIZABETH A. NEVILLE ��_0 ?�: Town Hall, 53095 Main Road
TOWN CLERK •;
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OFFICE OF TILE TOWN CLERK C t\ FC1 j- Application No.
`52'
ELIZABETH ATOWNNE ILLE,OF HOWN CLERK �OLD �
ELI �G $10.00 - Residential
P.O.BOX 1179 Cr, ;
SOUTHOLD,NEWYORK 11971 � �� $25.00 - Non-Residential
Telephone *0 [ ����'�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /eV/ZAD
OWNER NAME: ni'9ic/2-i ,4%,f ( /•`mac•
OWNER MAILING ADDRESS: /-2 ' '- 4Cr .Si
Ado-!(y //77,
OWNER PROPERTY ADDRESS: /S0 Ce,-=>'W F1b
Sa 1rnpL Z / A/j° •
OWNER TELEPHONE NUMBER: 7 `/y - 7'-3
TAX MAP NO. : Section lDDD Block 7/-'c Lot / 7- Z
CROSS STREET: /5//c*v2y 4i/E
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.)
Signature of47/
p
RECEIVED BY: 0 7/
Town Cl- 's Office
DATE:
1