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ELIZABETH A.NEVILLE ��_ O%; Town Hall, 53095 Main Road
TOWN CLERK % P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �+' Southold, New York 11971
MARRIAGE OFFICER �ifi �11, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �O, 'toe.
Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ��� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4121-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DOWNEY, JENNY
Mailing Address 1 11600 MAIN ROAD
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 1160 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 631-477-3617
Tax Map No. section 31 .00 block 14 lot 10.000
Cross Street STAR ROAD
Issue Date: 1/25/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
I OFFICE OF THE TOWN CLERK �FFO
TOWN OF SOUTHOLD ���R. COIj Application No. LI
P 1
ELIZABETH A.NEVILLE,TOWN CLERK � $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 . f;' $25.00 - Non-Residential
Telephone _Ol 4 ��0.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION.
-
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL AV. 4,
y td1O
Operation Permit No. Z U {
30
Fee $ L /
DATE
OWNER NAME: Cnl, DAAPIV-11)WI
I
OWNER MAILING ADDRESS: ( MD f11V
/.e)
se,s- rnAv n NNI 11,4,E 7
OWNER PROPERTY ADDRESS: _g]vi-,Q,
OWNER TELEPHONE NUMBER: /4-77 - ;Rol-7
TAX MAP NO. : Section � 1 Block /y Lot / 0
CROSS STREET: SUV 0
v
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool New Existing
Residential V 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.)
,......
25-----D
Si. :ture of App icant
RECEIVED BYt3()) ,
Town Clerk's Office
DATE: 1 ai-'I to--?./