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ELIZABETH A. NEVILLE 41= Town Hall, 53095 Main Road
TOWN CLERK ; y Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 4'7? Southold, New York 11971
MARRIAGE OFFICER y Fax(631) 765 6145
RECORDS MANAGEMENT OFFICER �,�Dl ������� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER - •'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4070-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner HELLERMAN, GLEN & LISA
Mailing Address 1 1170 BREAKWATER ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1170 BREAKWATER ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-523-8728
Tax Map No. section 106.00 block 9 lot 7.006
Cross Street MILL ROAD
Issue Date: 3/02/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
'C.OFOUr
OFFICE OF THE TOWN CLERK
Application No. `I r ro�O
TOWN OF SOUTHOLD
COG
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential L-
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 0 'W$� $25.00 - Non-Residential
Telephone = 1 Nei
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
t E . v En
for
OPERATION PERMIT FEB 2 2 2001
SEPTIC TANK or CESSPOOLav
urnora fawn Clerk
Operation Permit No. .J73 f.
Fee $ 10 : 010
DATE Q24/3f l
OWNER NAME: &L °-' l 2mc*v
OWNER MAILING ADDRESS: 100 eg ►K A n Ave-.
mfrir)-r'k,( t&Y
OWNER PROPERTY ADDRESS: )1'n 6 $ W -ADDRMfrrri Pi)/
ESS:TELEPHONE NUMBER: 631 - Sa3- 81
TAX MAP NO. : Section 10G Block "f Lot 7. Qt b
CROSS STREET: Mie,- fop,
TYPE OF SYSTEM: Septic Tank 1/ 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.)
attluct 1917,v1;10
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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