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ELIZABETH A.NEVILLE P$ Town Hall, 53095 Main Road
TOWN CLERK r<=' �� P.O. Box 1179
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Southold,New York 11971
REGISTRAR OF VITAL STATISTICS "_:
MARRIAGE OFFICER ®, - 1� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER � •�1'� Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER *,..
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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. 3757-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BARKIN, IRENE RAND!
Mailing Address 1 5 FARMSTEAD ROAD
Mailing Address 2
City St Zip COMMACK NY 11725-0000
Property Address 1 4040 BAYSHORE ROAD
Property Address 2
City St Zip CREENPORT NY 11944-0000
Owner Telephone No. 516-499-5877
Tax Map No. section 53.00 block 6 lot 27.001
Cross Street ISLAND VIEW LANE
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Issue Date: 2/04/98 ' zabeth A. N ville
Southold Town Clerk
(TOWN SEAL)
•
OFFICE--8F THE TOWN CLERK .0��F�
Town of Southold , ��� �CQ� Application No. 3 7`5 -
Judith T. Terry, Town Clerk . ...+:1'
Town Hall, 53095 Main Road ;*!' I $10.00 - Residential
P. O. Box 1179 U' ' " ' - �' $25.00 - Non-Residential
Southold, New York 11971 ��`
Telephone y1� '#4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
• DATE / pj_ 9d
OWNER NAME: 4Tek)7 /
OWNER MAILING ADDRESS: ch}e#,/� � �D
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OWNER PROPERTY ADDRESS : ' I� �t //„, ,' "D
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OWNER TELEPHONE NUMBER: 3/6 99y-ii-877
TAX MAP NO. : Section ,j� , U Block 6 Lot oa 7• (iCJ /
CROSS STREET: 1-SL/9-/V4 /✓cam / /IX/A--
TYPE
/IX/A-TYPE OF SYSTEM: Septic Tan < °'. New Existing
Cesspool 40 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.)
Artr?(--' 1241-fIc12-4° "2-ajt-1-4-466-4- 6
41,c:
Signature of Appl'cant
RECEIVED BY:
Town Clerk's Office
DATE: