HomeMy WebLinkAboutBurt, Clay o pf SO04,_
ELIZABETH A. NEVILLE ��II'`0� 49G)�� ; Town Hall, 53095 Main Road
TOWN CLERK * P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; G Q ,1 Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER l ^ ��. Telephone (631) 765-1800
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FREEDOM OF INFORMATION OFFICER '�`0�111'e��,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4360-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CLAY & ELIZABETH BURT
Mailing Address 1 PO BOX 809
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 7155 WICKHAM AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 631-298-2658
Tax Map No. section 107.00 block 5 lot 500
Cross Street ELIJAHS LANE
Issue Date: 10/19/07 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE i OTown Hall, 53095 Main Road
TOWN CLERK P.O.Box 1179
it Southold, New York 11971
REGISTRAR OF VITAL STATISTICSAf •
MARRIAGE OFFICER ‘ ' 4 Fax Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER et �',�� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER =.�'� illi southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 X or Non-Residential @ $25 Application No."4 3l0 0
Permit No. 3576R
Owner Name CLAY & ELIZABETH BURT
Owner Mailing Address P. O. BOX 809
MATTTTUCK, NY 11952
Owner Property Address 71 55 WICKHAM AVENUE
MATTITUCK, NY
Owner Telephone No. 298-2658
Tax Map No: Section 107 Block 5 Lot 5
Cross Street ELIJAH'S LANE
Please check each that applies: New Construction
Alteration to Existing System x
Residential X Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and a• • •ximate distance in feet from system to building
and closest road. New construction may su, � .opy of survey with SCHD approval.)
Sit. :ture of Applicant Date
Received by: elaftftg .14, • roiiq`c")
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CLAY & ELIZABETH BURT
7155 WICKHAM AVENUE
MATTITUCK
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