HomeMy WebLinkAboutEisen, Allison '•�,,o� SOUrol Town
ELIZABETH A. NEVILLE
1%s � wn Hall, 53095 Main Road
TOWN CLERK * * Y.O. Box 1179
REGISTRAR OF VITAL STATISTICS G � uuthold, New York 11971
MARRIAGE OFFICER . . Fax 1631) 765-6145
RECORDS MANAGEMENT OFFICER '�ry �, Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �CQUI�1' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4359-R Residential X Non-Residential
Fee $ 10..00 New Existing X
Name Of Owner ALLISON EISEN
Mailing Address 1 249 WEST 29TH STREET APT 3W
Mailing Address 2
City St Zip NEW YORK NY 10001-0000
Property Address 1 335 VILLAGE LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-903-1539
Tax Map No. section 25.00 block 2 lot 413
Cross Street ROUTE 25
47:2;64,4
Issue Date: 9/28/07 Elizabeth.A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ��� Town Hall,53095 Main Road
TOWN CLERK P.O. Box 1179
ae Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS v. Af
MARRIAGE OFFICER '� $ Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER y* 0.aI� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER = '� * �a�'� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 V or Non-Residential @$25 Application N I
Permit No. 19
Owner Name A`' ► 5tjn �S�
Owner Mailing Address Di ACA w 05k4)(1 ` P*, fit- AULD
k),(2..w ork \CXX)\
Owner Property Address 23F) \i‘Orly_ \...a1
Orta , \\ctSrl
Owner Telephone No. \ \- e - v, 6\u,-4Q3`1 Q
Tax Map No: Section \oc Block -Da Lot - 13
Cross Street - a
Please check each that applies: New Construction
Alteration to Existing System v'
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.)
Signature of Applicant Date
Received
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