HomeMy WebLinkAboutWilsberg, James (3) i,,00soFFOc,�"0
ELIZABETH A.NEVILLE = ' Town Hall,53095 Main Road
TOWN CLERK o - P.O.Box 1179
REGISTRAR OF VITAL STATISTICS : v✓ i Southold,New York 11971
MARRIAGE OFFICER �, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = Ypl �a��i�� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER •,,s" southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4264-R Residential X Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner WILSBERG, JAMES
Mailing Address 1 P 0 BOX 1429
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 665 BAILIE BEACH ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-298-5256
Tax Map No. section 99.00 block 3 lot 21.001
Cross Street EAST SIDE AVENUE
Issue Date: 9/16/04 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ELIZABETH A.NEVILLE :'''°
M`
Town Hall,53095 Main Road
TOWN CLERK t P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ; v, rov t Southold,New York 11971
O Fax(631) 765-6145
MARRIAGE OFFICER � ���
RECORDS MANAGEMENT OFFICER =y ���o' Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER O'� 4 �, 'i southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10or Non-Residential @$25 Application No. (7(°20'7
Permit No.
Owner Name .0—c. •e S W I I SV en- 3014 25- Z..
Owner Mailing Address 9.0‘g ox t y act
Owner Property Address Cis B0 1 I z gei ,eL QL. mak ;- ic_
Owner Telephone No. G3 I- a98- 526-6
i000
Tax Map No: Section c q Block 3 Lot Q I . I
Cross Street Ems' S'►1-c. Ave . /
Please check each that applies: New Construction �/
Alteration to Existing System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
. ct..Y._,9 9140H
Signatur-Q Applicant Date
Received by: _QZ_661,2
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