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G ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
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TOWN CLERK p P.O. Box 1179
r/� x Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �Y
MARRIAGE OFFICER Fax(631) 765-6145
��i � Telephone(631) 765-1800
RECORDS MANAGEMENT OFFICER ��d �a
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @ $25 Application No. �
Permit No.
Applicant Name t' `� !�► us-�Z�e�
Applicant Mailing Address 2-cI { �` f-a0'Pt4'K j J a[e. t i�7 5
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: Cpe t_t" jZv 6,'v" 11A Lk r
Owner Mailing Address: -�-ci !� 6 S -F/A (.� + e► l l� ( i 17-3 s-
Owner Property Address: 0 2® Lv ``t q Ci-,,-eAe 61-
Name
r-Name and phone number of contact person
Tax Map No: Section 6 Block I Lot l V
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICA`T'ION. NEW
CONSTRUCTION RE QUIRES SURVE ITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant _ Date
Received by:
5UR\/EY OF P/O BU I LD I N6 AREA LOT 5
MAP- OF M ILL GREEK PRE5ERVE
FILED AT THE OFFICE OF THE CLERK OF SUFFOLK GOUNTY
JAN. 2.8, 2005 AS FILE NUMBER 11216
SITUATE: ARSHAMOMOME
TONN: SOUTHOLD
SUFFOLK COUNTY, NY <0�c
SURVEY 06-•22-2016, REVISIONS 10-11-201(o
SUFFOLK COUNTY TAX # \�
P/O 1000 - 56 - I - 11.3 ���"� �Jo
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NOTES:
MONUMENT FOUND
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GRAPHIC SGAI_E: 1"= 50'