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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) 11# SUFF0t4/� ,0 4Q'\ 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 w 7 • v ' -