HomeMy WebLinkAboutRussell I�#111 9FFOUr
11"ELIZABETH A.NEVILtE t� � %,7,4�` Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS V. '�� Fax(516) 765-1823
MARRIAGE OFFICER � #4 ®�'�� Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER � �Q • �l
FREEDOM OF INFORMATION OFFICER •
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3761-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RUSSELL, LEO D.
Mailing Address 1 5550 BERGEN AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-1429
Property Address 1 5550 BERGEN AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-1429
Owner Telephone No. 516-298-4982
Tax Map No. section 56.00 block 1 lot 2.003
Cross Street COX NECK LANE
Issue Date: 2/13/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK l\FFO
,�
TOWN OF SSOUTHOLD , ��%,; • _CSG � pplication
ELIZABETH A.NEV,LLE,'I'OWNCLERK M,. �� $10.00 - A Residential
ek4s
0.0.BOX 1179 tJ7
SOUTHOLD,NEW YORK 11971 :, ; ,. � ,�� $25.00 - Non-Residential
Telephone.( , st$
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE )"
OWNER NAME: k 1 ' /J ied-S 5'6 2,e__
OWNER MAILING ADDRESS: .`",.5-5-e,
7-1/ /I-P-Sz,--/-S_s-2-.0
OWNER PROPERTY ADDRESS: SiFI,4-7,4'
OWNER TELEPHONE NUMBER: ( -/'h ) o29e-Ss98,-. -
y TAX MAP NO. : Section /4120 Block Lot .5" a 3
CROSS STREET: CoxA4—
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing d�
Residential k 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office -
DATE:
e_17---S:,
555 B cv2
/OC2 3
Poq
6 6 N
46 4,u
/4-sir
•WCL