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ELIZABETH A.NEVILLE = d: Town Hall, 53095 Main Road
TOWN CLERK ; y Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �����, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER � �l 4:00
. ,,� Fax
(631) 765-1800
FREEDOM OF INFORMATION OFFICER ���
OFFICE OF THE TOWN CLERK
SOUTHOLD WAIEFIHWATERTE1131610SAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4091-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner GATZ, THOMAS
Mailing Address 1 EAGLES NEST COURT
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 EAGLES NEST COURT
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-298-5961
Tax Map No. section 127.00 block 9 lot 8.000
Cross Street WHITE EAGLE DRIVE
Issue Date: 7/09/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OFTHE TOWN CLERK O�jVFFfle • A liNo.Y5
TOWN OF SOUFHOLD ; `�. ppCation ✓.
ELIZABETH A.NEVILLE,TOWN CLERK � �� .�% $10.00 - Residential
P.O.BOX 1179 •
SOUTHOLD,NEW YORK 11971 0 ';' $25.00 - Non-Residential
Telephone _�.( NO-141�'
(516) 765-1801
t TOWN OF SOUTHOLD P- e_h r\i o‘ 0011.4--
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w, C SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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U = o APPLICATION (e)-Ae'\
ar i
for
t( -7 ,Q__
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 1 ' (-' "(-21
OWNER NAME:
l O,n,\w S Gt,R r-2-
OWNER
r2-OWNER MAILING ADDRESS: F iAfi'_L.op w_rts r Csa-���
ULA✓r I41 1–vdA-- PH
OWNER PROPERTY ADDRESS: C.4A1 GJQ f...)-to SI— 1J1 (
OWNER TELEPHONE NUMBER: \ 2/'g -" Sit G /
TAX MAP NO. : Section k000 Block V ICI Lot 01 - 06
CROSS STREET: Vv l-f'lrc '1JAM1)lvNZ
TYPE OF SYSTEM: Septic Tank ✓ New Existing
`�
Cesspool New Existing
17
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.)
p/Sinatu fe of ' pp icant
RECEIVED BY: .
Town Clerk's Office
DATE:
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