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ELIZABETH A.NEVILLE ' �0 l0 Town Hall, 53095 Main Road
TOWN CLERK * Rig t P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � G Q ,� Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER . l 'rN • Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ` '#COUn►1+� .�•
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, southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4362-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MICHAEL J VERITY
Mailing Address 1 PO BOX 476
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 405 SOUND ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 631-477-9417
Tax Map No. section 35 block 1 lot 430
Cross Street CR 48 & SUTTON PLACE
Issue Date: 10/22/07 lizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ,III.0‘0 O4`� Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179 •
y = ; Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS % v. At ‘
MARRIAGE OFFICER : 046 '"$ Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER \ 'if V-le Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER -?O'� ��.'� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10or N1,Zon-Residential @ $25 Application No. 93 to g.,
Permit No. 33.s( ie.
Owner Name ' '-'t"'"/""
Owner Mailing Address , . a 07=7 117 4.
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- 972, //5 44
Owner Property Address 1204.04.5—
‘-''Vt-ees.,•-.,-- - Q21- //? i�
Owner Telephone No. 6 3 i) 17°7 7 _ ! 11 7
Tax Map No: Section 3$ Block / Lot '3 (,Z Li" #)
Cross Street ,e__ 48 /���-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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Signature of Ap cant ate
Received b ‘ AV/in i,.ti,�
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0x19 COMPANYCFCANT CF NEW N Survey for:
MICHAEL J. VERITY
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Town of `,r
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Suffolk County New York 1A 35`3AT
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“SUNSET AVENUE (
9ESTNAIPTON REAM N.T.11978 NOTES
031)299-0022 t,AREA 211,139 S.F. J
2.A-MONUMENT FSF. ♦ 070(0 FOUND,
1 MIFNENCE DEED;1..11049 P.59.
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