HomeMy WebLinkAboutBrunet, Beverly (3) SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4326-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BEVERLY BRUNET
Mailing Address 1 184 MARCELLUS ROAD
Mailing Address 2
City St Zip MINEOLA NY 11501-0000
Property Address 1 540 VANSTON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-747-0916
Tax Map No. section 104.00 block 12 lot 900
Cross Street
Issue Date: 10/26/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ELIZABETH A.NEVILLE /0 4 Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
_ ; Southold New York 11971
REGISTRAR OF VITAL STATISTICS v. PP, '
MARRIAGE OFFICER : G I Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �. a� ei� 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
Residential @$10 I or Non-Residential @ $25 Application Nog 32-Lo
Permit No.
Owner Name Iy inr u Ile +-
Owner MailingAddress 1tl a r G e 1 u SCA
Nlene0I4 N ) 115-vl
Owner Property Address 6 Va Y) SI-o "7 Pc(i
u te_ 110 5 u e ti y l � q3s
Owner Telephone No. 57 (v '7 y 7 - v qr / 4,
Tax Map No: Section / U`f'a U Block / Lot 7. 0 w
Cross Street
Please check each that applies: New Construction
Alteration to Existing System
Residential i/ 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.)
/13—e /&c-C-rtr.
6/0
Signature of A icant Date
� p
Received b
AS N CESSPOOL, DRAIN ' R
L I 11935.
631.74-6585
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