HomeMy WebLinkAboutSmith, Justin ,,,, iii
ELIZABETH A. NEVILLE !' '` O L
• � Town Hall, 53095 Main Road
TOWN CLERK * * P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ; G Q ��
MARRIAGE OFFICER ,' . ) • Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER `.-44 � •�� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER QU ;,I��sie
southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4349-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner JUSTIN SMITH
Mailing Address 1 1040 FOUNDERS PATH
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 SAME AS ABOVE
Property Address 2
City St Zip 00000-0000
Owner Telephone No. 631-765-0085
Tax Map No. section 64.00 block 2 lot 15
Cross Street LANDON LANE
Issue Date: 8/07/07 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ELIZABETH A.NEVILLE ih`1` Gy Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
Z ; Southold, New York 11971
REGISTRAR OF VITAL STATISTICS k v.
MARRIAGE OFFICER '� 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �=y� O0�i�l Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER =O'� ''iii �a�'i southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 L or Non-Residential @$25 Application No. 12..7
Permit No. 43 Li e
Owner Name ji,i sr 1, 11 J • ci n /I- H
Owner Mailing Address (O`I o fOL-( Vl Eek s fiii- H
(4+O16 Ai (--/ ( / 92/
Owner Property Address /0116 ro a ri de 0Z_5 pec) r H
SQ i i-kd / n � v L ,r 47/
5
Owner Telephone No. G. ?/- 7 QC 6S
Tax Map No: Section y' 00 Block Z Lot ['S 0 0
Cross Street L IAi nO i L- G fel e--
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.)
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Received by:-6)P
NDERS ESTA TES" FILED
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■=MONUMENT
ANY ALTERATION . ' ,'InON 70 THS MALEY i A .4OLA770N
OF SECTION ,L NEW YORK STATE EDUCA770N LAW.
EXCEPT AS PEN ' 7209-SIJEWINSTON 2 ALL►CER77F7CA770N
HEREON ARE a' THIS MAP MID CAS THEREOF ONLY IF
SAID MAP OR, • A 'AR THE IMPRESSED SEAL OF 7HE SURVE
NNOSE SOU ,.,r*,, ARS HEREON.