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ELIZABETH A.NEVILLE,RMC,CMC l0 Town Hall, 53095 Main Road
TOWN CLERK I l #[ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS y Southold, New York 11971
MARRIAGE OFFICER COQ Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Oly Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER CDU�y 1�,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4401-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ROBERT TIE
Mailing Address 1 P 0 BOX 437
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i
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000c
o
Property Address 1 580 SMITHS DRIVE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-765-8294
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Tax Map No. section 76.00 block 2 lot 15.000
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Cross Street MAIN BAYVIEW ROAD
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Issue Date: 10/02/09 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLEo� y� Town Hall, 53095 Main Road
TOWN CLERK C 2 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER y • �� 1 Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ��l `t►aO Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10--SL or Non-Residential @$25 Application No.
Permit No.
Owner Name � e
Owner Mailing Address
Owner Property Address
Owner Telephone No. ``US ag4A
Tax Map No: Section __\Co.Q Block Lot
Cross Street
Please check each that applies: New Construction
Alteration to Existing System
Residential ✓ Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
afore of Applicant Date
Received by: *0
-' - rly`1 ` ' ' - ' -. ice = 1 , 11 ' ' , -- ' r -, - � `- ." _ � _. ` I •, `� ,- 1'- �.,
AL
TUNE CESSPOOL"$z=DIZAi1�T.SERVICE
COAS. 0.
4225 Bridge-L-ane
- _.Cut&ogue,L.L,-N.Y:.i 935,
SCCA Lic.'#168-LW= : 4 NYS DEC,#'1A-6,00