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ELIZABETH A.NEVILLE e®°� y • Town Hall, 53095 Main Road
TOWN CLERK �� P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS w Southold,New York 11971
® >' ��� Fax(516) 765-1823
MARRIAGE OFFICER ; 0.1 Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER ® i
FREEDOM OF INFORMATION OFFICER '. a *0
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3795-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner JENSEN, KEITH R. AND TERRY A.
Mailing Address 1 120 KORN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 01197-0000
Property Address 1 120 KORN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1897
Tax Map No. section 64.00 block 2 lot 2.000
Cross Street HOBART ROAD
Issue Date: 6/16/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COMir
`;' 75
TOWN OFSOUTHOLD `� Application No.
ELIZABETH A.NEILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179 cr3
SOUTHOLD,NEW YORK 11971 1��� $25.00 - Non-Residential
-- Telephone 0,( 0:0°.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 6,4 le
OWNER NAME: eErn.t 2, gl / A-, j ,N1 ,AD
OWNER MAILING ADDRESS: 12 ,\49e1 10.0
OWNER PROPERTY ADDRESS: 5 ,c- -6Ag-
OWNER TELEPHONE NUMBER: •77(. -a f€97
TAX MAP NO. : Section (' Block 2 Lot 2
CROSS STREET: 1--o3-
TYPE OF SYSTEM: Septic Tank V New Existing v(
Cesspool V 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.)
Signaturdcr Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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SURVEY FOR •
REFERENCE;
KEITH JENSEN o• TERRY J - . - '
\ AT SOUTHOLD ' �t° • �'% - '
TOWN OF SOUTHOLD g�aosoj•a E4�r .-.ft Rt/ARANTEED TO.
SUFFOLK COUNTY, N.Y 0 t ,Rsr AMERICAN TITLE INSURANCE casupjNr OF
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■ urHOLD SAVINGS-BANK " ,
\ SCALE• I ■ 30' r :7i•"!
Of� /rN-JENSEN ® 1fFA' :JENSEN
NO V. 25,/98/ °p - _-...3 - �A
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Fb LAND`�J LANAI eURVEYOR
NLS LIC NO.ES7EQ
- RIVERHEAD,N Y. 1
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