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ELIZABETH A.NEVII.LE t`;,,*, Town Hall, 53095 Main Road
TOWN CLERK P.O.
� F � � P.O. Box 1179
Virt) !j ;` X1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ®I'll Fax(516) 765-1823
MARRIAGE OFFICER ..- 'Qi •as�11 Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER i�
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. 3810-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SCHALLER, ANNA M.
Mailing Address 1 5 HIDDEN OAK ROAD
Mailing Address 2
City St Zip ARMONK NY 10504-0000
Property Address 1 115 PARSONS BLVD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1124
Tax Map No. section 37.00 block 2 lot 5.000
Cross Street DOGWOOD LANE
Issue Date: 8/26/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK s\FF®(A-
TOWNOFSOUTHOLD ..c Application No. E-16
ELIZABETH A.NEVILLE,TOWN CLERK � < $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 $25.00 - Non-Residential
Telephone Sol aid 10-1,(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (O •. ( j
DATE 01off
OWNER NAME: kV/VA-- 1\1 5 c(.4-( 1-1,
OWNER MAILING ADDRESS: 14( ® p 0,41< R
-RR frto A)
OWNER PROPERTY ADDRESS: /! 5 PAR soli" S l3 PVD
EJ1Ad, i61 y ( 737
OWNER TELEPHONE NUMBER: 57G t 7 " / f '3-4
TAX MAP NO. : Section S 7 Block Lot -3'
CROSS STREET: L
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1/ New t 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.)
j462--eat-
Signature
of Applicant
RECEIVED BY:
/` Town Clerk's Office
DATE: �/ ����
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