HomeMy WebLinkAboutSmith SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4422-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WILLIAM J SMITH
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Mailing Address 1 P O BOX 1238
Mailing Address 2
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City St Zip CUTCHOGUE NY 11935-0000 SWN��U1
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Property Address 1 46530 ROUTE 25 pk 0
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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. 000-000-0000
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Tax Map No. section 75.00 block 3 lot 3.000
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Cross Street SOUTH HARBOR RD
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Issue Date: 10/08/10 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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G
ELIZABETH A.NEVILLE y� Town Hall, 53095 Main Road
TOWN CLERK � g P.O. Box 1179
REGISTRAR OF VITAL STATISTICSO Southold, New York,11971
MARRIAGE OFFICER y • ®�� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �ol ( �a 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
i
Residential @$10 or Non-Residential @$25 Application No.
Permit No.
Owner Name O. rnn
Owner Mailing Address�q(D b c*(
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Owner Property Address
Owner Telephone No.
Tax Map No: Section
\ r 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.)
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Signature of Applicant Date
Received by.
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C®ASTLINE-CLSSX-10 DRAIN SERVICE
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