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OFFICE OF THE TOWN CLERK I�FCOIjFO .
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TOWNOFSOUTHOLD � � Application No. 3
ELIZABETH A.NEVILLE,TOWN CLERK :44 $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 � $25.00 - Non-Residential
Telephone i )0)°;./
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for g6 2�2�
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3/)/6
OWNER NAME: ERS` A
OWNER MAILING ADDRESS: ( 5- 8 1 k
sd ko LD L) l IR )l
OWNER PROPERTY ADDRESS: , ' p t'1
OWNER TELEPHONE NUMBER: 3 / C 5 ;--7
TAX MAP NO. : Section —7, D Block )— Lot t . d 03
CROSS STREET: C.c-) RCZ. D
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing/
Residential 11 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.)
aeg-e-L79-
Signatu of Applicant
RECEIVED BY:
own Cler 's Office
DATE: 3/7/0(