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ELIZABETH A.NEVILLE ,�4° ��; Town Hall, 53095 Main Road
TOWN CLERK ® 41,: P.O. Box 1179
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REGISTRAR OF VITAL STATISTICSy.iFax Fax(516) 765-1823
MARRIAGE OFFICER �� J�-_ _ civ. � Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER : ""®/T `Ls' i
FREEDOM OF INFORMATION OFFICER ��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3756-R Residential X Non-Residential
Fee $ 10.00 New Existing X _
Name Of Owner HIGGINS, L. PATRICK
Mailing Address 1 205 WATCHUNG FORK
Mailing Address 2
City St Zip WESTFIELD NJ 07090-0000
Property Address 1 580 OLD SALT ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4528
Tax Map No. section 144.00 block 5 lot 12.000
Cross Street ROCHELLE PLACE AND BAY AVENUE
Issue Date: 2/04/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3V rDU( '
Town of Southold &,N) CQ Application No. 3 75,6
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road § -< $10.00 - Residential
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P. O. Box 1179rN �Z' $25.00 - Non-Residential
Southold, New York 11971 O ®= `i ,�0•�`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 7 ,/U6
22/9ODATE 7/22/9-7-
OWNER
WNER NAME: t, /141W/C74 M6-61/l.s
OWNER MAILING ADDRESS: doe, giert-tU/U!r , j/k
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OWNER -PROPERTY ,'DDR ESS : - 00 OM •
OWNER TELEPHONE NUMBER: 5A; 0994 - Ysali
TAX MAP NO. : Section 74/41 Block C. Lot /.2_
CROSS STREET: ilde '``'e ftf,2! f /51
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TYPE OF SYSTEM: Septic Tank NewExisting
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.)
Signatu jr-APplicant
RECEIVE
RECEIVED BY:
T n ,�Cler 's Office
JAN 19
'd DATE:
Southold Tom Clare
OLP Rork)
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