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ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
TOWN CLERK 2 P.O. Box 1179
��, Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ���® ®��il Fax(516) 765-1823
RECORDS MANAGEMENT OFFICERlig ���1 Telephone(516) 765-1800
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. 3803-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CHAMBRUN, CLAIRE A.
Mailing Address 1 840 PINEWOOD ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 840 PINEWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7496
Tax Map No. section 116.00 block 5 lot 23.000
Cross Street SOUTHERN CROSS ROAD
47
Issue Date: 7/27/98 " izabeth A. vi e
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFU
TOWN OF SOUTHOLD 0� COG Application No.- '
, ELIZABETH A.NEVIJ.J.E,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
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SOUTHOLD,NEW YORK 11971 • $25.00 - Non-Residential
Telephone- • Oj `
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE -TU/yea , Mgr
OWNER NAME: (L /i/'i /4• C A M,8°feoV
' OWNER MAILING ADDRESS: ?4L6f 7/1JL� We D
l; (17--CR-0 0 f A
• OWNER PROPERTY ADDRESS: -579-enf�
OWNER TELEPHONE NUMBER: (7L) 73`:— 75'(c
TAX MAP NO. : Section /16 Block (-5-- Lot 023
CROSS STREET: SO07 -tEkit) CiR®S'S Q/9 a
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X 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.)
a. & A C)
Signature of Applicant
RECEIVED BY: •
Town ' = Office
DATE:
JUL 211990 - -
Southold Tom Mgt
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