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FOUris
ELIZABETH A.NEVILLE
�1/�® Town Hall, 53095 Main Road
� y� :
TOWN CLERK ® 1 P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �� Fax(516) 765-1823
MARRIAGE OFFICER � x'10 Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER � ®� i
FREEDOM OF INFORMATION OFFICER �a,/.��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3775-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KIRWIN, JOSEPH AND MARY
Mailing Address 1 RR 1, BOX 4955 PINE TREE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4955 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6794-
Tax
16-734-6794Tax Map No. section 138.00 block 2 lot 3.003
Cross Street SKUNK LANE
Issue Date: 3/17/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
/
• OFFICE OF THE TOWN CLERK �FFO �J��
TOWNOFSOUTHOLD
, � COy Application No. � / 7 J
ELIZABETH A,NEVILLE,TOWN CLERK -: FY $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEWYORK 11971
6
3• $25.00 - Non-Residential
- -• Telephone - 0.(
(516) 765-1801
TOWN OF SOUTHOLD -
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • - -- - - - - -- - - - - - _
•
DATE
- 46 /9r,
OWNER NAME: 7;58-0-11 MA Ry k( RI,f1 /Al
OWNER MAILING ADDRESS:6111 ,&' J//VV
-T�1-(a / (,36'
OWNER PROPERTY ADDRESS:
J,.
OWNER TELEPHONE NUMBER: 576 _ 3 y *7? g-
TAX MAP NO. : Section 1 lock cg' Lot 3
CROSS STREET: Al
TYPE OF SYSTEM: Septic Tank /- New Existing
Cesspool v New Existing
9
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.)
" 1
ignature of Applicant
RECEIVED' BY: Aj, l" ;
own Clerk's Office -
DATE: -5 l�
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