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ELIZABETH A.NEVILLE , ' ®may Town Hall, 53095 Main Road
TOWN CLERK ; ® P.O. Box 1179
ass Southold,New York 11971
REGISTRAR OF VITAL STATISTICS rvir'�� Fax (516) 765-1823
MARRIAGE OFFICER �®
� �� ®�I��� Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER `'s ®1 �/���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3842-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CANNON, ANGELIA C.
Mailing Address 1 P.O. BOX 671
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 640 ORCHARD STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5446
Tax Map No. section 55 block 2 lot 40.100
Cross Street SECOND STREET
Issue Date: 12/21/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
"I..OFFICE OF THE TOWN CLERK �S�FFD(,j
TOWN OF SOUTHOLD � CSG Application No:3a
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 *.$ $25.00 - Non-Residential
94
. -, -- Telephone ®/ 4(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /�/ // 27
OWNER NAME:
OWNER MAILING ADDRES: p, C7 .P•a-0 4o 4 7
OWNER PROPERTY- ADDRESS:- -
OWNER TELEPHONE NUMBER: `7 —S`I 4/
TAX MAP NO. : Section ( Block 2. Lot Lf, /
CROSS STREET: ,,,
TYPE OF SYSTEM: Septic Tank 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.)
Signature of Applicant
RECEIVED BY:
f Town Clerk's Office
/
DATE: �70- /7
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