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ELIZABETH A.NEVILLE ��I y Town Hall, 53095 Main Road
TOWN CLERK o P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER .�1,iL ��
RECORDS MANAGEMENT OFFICER "fel ��,411 Fax(631) 765 6145
10 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. 4179-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner OLSEN, GREGORY & DARLENE
Mailing Address 1 P 0 BOX 158
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 6645 GREAT PECONIC BAY BLVD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 631-298-5787
Tax Map No. section 126.00 block 10 lot 20.000
Cross Street BRAY AVENUE
Issue Date: 12/27/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
iso
'OFFICE OF THE TOWN CLERK
TOWNOFSOUTHOLD 0��5 lj Application No. VW
ELIZABETH A.NEVILLE,TOWN CLERK '
G $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 �� $25.00 - Non-Residential
Telephone = 1 4( '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ le) ' CP6
DATE $ N 02.
OWNER NAME: 611-e A P•
OWNER MAILING ADDRESS: P,O,6o-K 1 S & t,oure. /v, 7, J) cLf g.
OWNER PROPERTY ADDRESS: 616 f eco*rte /S/1-`f is ,,,/
C,_a_u-t.-( aJ" 7.
OWNER TELEPHONE NUMBER: 6 3 ( 0Z 9 Ft C?? 7
TAX MAP NO. : Section 1 6 Block id Lot c20
CROSS STREET: OR Ph/
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.)
if.nature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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GREG OLSEN
6645 PECONIC BAY BOULEVARD
LAUREL
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