HomeMy WebLinkAboutBergen, Bruce / of' OFFOL j'
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ELIZABETH A.NEVILLE /_ �: Town Hall, 53095 Main Road
TOWN CLERK ; H Z $ P.O. Box 1179
v. Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER � y10Agg �1 Fax (631) 765 6145
RECORDS MANAGEMENT OFFICER -_ ,� .������' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER '/,,r��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4071-R Residential X Non-Residential
Fee $ 100.00 New X Existing
Name Of Owner BERGEN, BRUCE AND LEIGH
Mailing Address 1 PO BOX 1198
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3965 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-298-2627
Tax Map No. section 107.00 block 100 lot 20.006
Cross Street REEVE ROAD
Issue Date: 2/23/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK SIT Mir
CD Application No. 07
ETH A.NEVILLETOWN OF SOUTHOLD
TOWN CLERK - PP'�� 1
G $10.00 Residential
P.O.BOX 1179
SOUTHOLD,NEWYORK11971 ;i $25.00 - Non-I esidential
Telephone . 01 44
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 232 '--A
Fee $
DATE /a/
OWNER NAME: O2c,c
OWNER MAILING ADDRESS: ?e7 ,4cDY /796r
Z-,- 77 7 4'' f( W 7 //9J
OWNER PROPERTY ADDRESS: 376.5— 644'x,•,2 ,Qvf
JTzrvL/( , //6/-
OWNER
fti/OWNER TELEPHONE NUMBER: ,29,17_,z2 7 w
TAX MAP NO. : Section /e'2 vv Block / Lot 0 , o a C
CROSS STREET: /4' 9 v
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.)
/2/1
Signature of Applicant
RECEIVED BY: 'g
Town Clerk's Of
DATE: 7
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