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ELIZABETH A.NEVILLE ;� ~� d • Town Hall, 53095 Main Road
TOWN CLERK 2 Z J P.O.Box 1179
REGISTRAR OF VITAL STATISTICS �O / Southold, New York 11971
MARRIAGE OFFICER "Of _,I •0 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER : 1 * �►„..° Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER ,.,,,.•'� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
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Residential @ VA-4'0r Non-Residential @$25 Application No.
Permit No.
Owner Name /0 i)v �crJ.sc..•J
Owner Mailing Address <91 ct L A.I S
Owner Property Address
(gft�,-t Portes
Owner Telephone No.
Tax Map No: 2 you Section lir Block .3 Lot 3
Cross Street iU 1.,.I 7H
Please check each that applies: New Construction yi
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.)
Signa o Applicant D to
Received by: "tel,
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