HomeMy WebLinkAboutSherlock, Frank ELIZABETH A.NEVILLEG'fd;
OFFICE OF THE TOWN CLERK C§IF /G
TOWNOFSOUPHOLD 0� COG Application No. 7O-7
)I.IZABB TH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971
C.11 $25.00 - Non-Residential
Telephone .4! * `ge°, '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.a�-95
Fee $ ! D ,00
DATE 1(2 _ 50c,
OWNER NAME: -FS4i k S-LK
OWNER MAILING ADDRESS: /!15'Rrefl u)A e c- rR Q
ioy
OWNER PROPERTY ADDRESS: /5-5- B reAJ jijM r
OWNER TELEPHONE NUMBER: 4,3' 02q? g3lam/
TAX MAP NO. : Section / 15 Block coca Lot
CROSS STREET: ( i) ---ROAd.
TYPE OF SYSTEM: Septic Tank New oir Existing
Cesspool New 1/ Existing
Residential ,/ Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
CfsS �,�l5
of d'stance,j approximately, to building and closest road.)
A m� ASr
/ 1 ,
Signature of App icant
RECEIVED BY:
XTown
Ce( rk's Office
DATE: !�$/6