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ELIZABETH A.NEVILLE /C Town Hall, 53095 Main Road
TOWN CLERK � ® P.O. Box 1179
Southold,New York 11971
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REGISTRAR OF VITAL STATISTICS � ' Fax(516) 765-1823
MARRIAGE OFFICER ✓� ® e,'' Telephone(516) 765-1800
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RECORDS MANAGEMENT OFFICER � ^
FREEDOM OF INFORMATION OFFICER s
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3771-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BLAIKIE, JANE
Mailing Address 1 P. 0. BOX 40
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 6925 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-7311-6897
Tax Map No. section 111 .00 block 15 lot 9.000
Cross Street BRIDGE LANE
Issue Date: 3/05/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'coFour
TOWN OF SOUTHOLI) `t• %` ' 0G Application No.337-7/
ELIZABETH A.NEVILLE,TOWN CLERK ' „ 't" ? .' $10.00 - Residentia I -�
P.O.BOX 1179 �,
SOUTHOLD,NEW YORK 11971 �'i' 'n. 0:): �,��� $25.00 - Non-Residential„r
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Telephone 01 *N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. .
Fee $ /0 *
DATE �(7j4:i
OWNER NAME: ' I” t I 1 A' k` I 6
OWNER MAILING ADDRESS: '` O) if®
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OWNER PROPERTY ADDRESS,: 6 9,25- " 4-59,4 Ft , Kd
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OWNER TELEPHONE NUMBER: „cgs, 134- 6.s1"/
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TAX MAP NO. : Section /'I Block lb Lot q
CROSS STREET: 1 K10 & IBJ Lfr'/I
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool New Existing �/
Residential V/ 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.)
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Signature of Applicant
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RECEIVED BY: LL)/()/1-----'
wn Clerk's Office
DATE: ��
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