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ELIZABETH A.NEVILLE I y® Town Hall, 53095 Main Road
TOWN CLERKSc® P.O. Box 1179
t CO2 2 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �I Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER
MARRIAGE OFFICER L 4i34- Telephone Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER 491 41 �`�,80.
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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. 3844-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CLEW, CLAIRE & MICHAEL
Mailing Address 1 PO BOX 188
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 1805 MILL ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-323-3931
Tax Map No. section 56.00 block 1 lot 11.003
Cross Street BAY HOME ROAD
Issue Date: 12/22/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �COFDC,t" .
TOWN OF SOUTHOLD Off. ,.; . COIj��' Application No. 7.2t
ELIZABETH A.NEVILLE,TOWN CLERK �` -;_ $10.00 - Residential
P.O.BOX 1179 cr3J*� z' $25.00 — Non-Residential
SOUTHOLD,NEW YORK 11971
Telephone - • '.( NOV
•
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /2--/2--q.9•
OWNER NAME: ((67 (re f A'fc-ILaa-( CJ/ (-4t
OWNER MAILING ADDRESS: Pd el-OK
06- " A/(q
OWNER PROPERTY_ADDRESS: [ F-0.5
4-
si4iofrL
1 A/ (/CK//
OWNER TELEPHONE NUMBER: �-3-3 0/ 3/
TAX MAP NO. : Section c6 Block I Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank
t.7--New Existing
Cesspool ✓ New `� Existing
Residential Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
i
Signa ure of Applic' t
RECEIVED BY: 111(AA--
r
own Clerk's Office
DATE: /2- 2 / / .or
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