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ELIZABETH A.NEVILLE ,4/41/4"'�® Gym; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
2 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ,�� Fax(516) 765-1823
MARRIAGE OFFICER :`V4 /
RECORDS MANAGEMENT OFFICER 41 *pi"
a �� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER - II,��
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3777-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HALPIN, JULIE
Mailing Address 1 ' 333 EAST 30TH STREET #19N
Mailing Address 2
City St Zip NEW YORK NY 10016-0000
Property Address 1 220 SKIPPERS LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 212-686-6078
Tax Map No. section 25.00 block 1 lot 21 .000
Cross Street VILLAGE LANE
Issue Date: 3/23/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�vFFRA- -
Town'of Southold k� CQG Application Ne-7272
Judith T. Terry, Town Clerk .� , _
• Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179
$25.00 - Non-Residential
Southold, New York 11971 O
Telephone j-40
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•
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O OO
DATE 4/00
OWNER NAME: ',
OWNER MAILING ADDRESS: 333 3D,..csfr .dt /QA)
a<.° aie-k i iV 1®N&
OWNER PROPERTY ADDRESS: 0:2::1(5Skippjut
evitth. Nitro yogic 1195r1
OWNER TELEPHONE NUMBER: j� —(pj —69098°
TAX MAP NO. : Section 0/ 5 Block 1 Lot 0/
CROSS STREET: KAACT, 1.11/1-t)
TYPE OF SYSTEM: Septic Tank 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.)
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Signa re of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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