HomeMy WebLinkAboutArin, Risa t OFFICE OF THE TOWN CLERK C�VF FOUr '.
TOWN OFSOUTHOLD �� Application No. VsMi6.
BLIZABETH A.NEVILLE,TOWN CLERK • $10.00 - Residential
P.O.BOX 1179 '� �
SOUTHOLD,NEWYORK 11971 �� $25.00 - Non-Residential
Telephone .4j `��, 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT RECENED
APPLICATION DEC 2 6 2000
for __..
Semibold Town perk
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. \j\-
Fee $
DATE is 11?100
OWNER NAME: RS / Z/ii
OWNER MAILING ADDRESS: sr Al AM NV
i 000,3
OWNER PROPERTY ADDRESS: l g SounjD G4UE..
IDC--C 1C_ 'y
OWNER TELEPHONE NUMBER: 2J Qi,O
TAX MAP NO. : Section Block Lot 3
CROSS STREET: t---/ / LL. RD
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New X 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 ofQç) z\
pcant
RECEIVED BY:
Town Clerk's Office
DATE:
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