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ELIZABETH A. NEVILLE ��= yd• Town Hall, 53095 Main Road
TOWN CLERK ; H P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ‘‘344‘&
Al Southold, New York 11971
MARRIAGE OFFICER : ifi Fax Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER N. �Ql $ '••1 Telephone (631) 765 1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
SOUTHOLD INARITEYMMIRITICHIMSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4084-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner HAGERMAN, CHARLES
Mailing Address 1 PO BOX 278
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 465 HALL'S CREEK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-298-3206
Tax Map No. section 116.00 block 7 lot 32.000
Cross Street NEW SUFFOLK AVENUE
ArY+4,4 .f.,d‘
Issue Date: 5/09/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �SUFFO(,r`" `�
TOWN OFSOUTHOLD �,� Application No. D
ELIZABETH A.NEVILLE,TO N CLERK ,.4 $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 0 � $25.00 - Non-Residential
,.
Telephone 70 4 1 oma
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE �(� a(
OWNER NAME: (C14 1`--{-S 1" `r`(tE e-kpl
OWNER MAILING ADDRESS: CO
OWNER PROPERTY ADDRESS: +(OS 14r11k- gt - wc0E
rft-Tri T v&K-- !at l IRSD-
OWNER TELEPHONE NUMBER: 2-9g - 3o(
TAX MAP NO. : Section II (' Block O7 Lot 3 ,
CROSS STREET: 060 SU %f VE
TYPE OF SYSTEM: Septic Tank I 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.)
ignatu - of Applicant
RECEIVED BY: AZ
Town Clerk's ice
DATE: / Q
4.i 14, I
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