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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4479-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner ROBERT & SUSAN GATEHOUSE
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Mailing Address 1 3 RED ORANGE ROAD
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Mailing Address 2
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City St Zip MIDDLETOWN CT 06457-0000
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Property Address 1 2870 PECONIC BAY BLVD
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Property Address 2
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City St Zip LAUREL NY 11948-0000
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Owner Telephone No. 860-346-6926
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Tax Map No. section 128.00 block 6 lot 11.000
Cross Street WENDY DRIVE
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Issue Date: 12/27/12 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL) "
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ELIZABETH A. NEVILLE y� Town Hall,53095 Main Road
TOWN CLERKC2'*
Z P.O. Box 1179
REGISTRAR,OF VITAL STATISTICSO Southold, New York 11971
MARRIAGE OFFICER ! y�S a��� Fax(631) 765-6145 -
RECORDS MANAGEMENT OFFICER 1 �► 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 -./or Non-Residential @ $25 Application No. LL47
Permit No. I7
Owner Name Rw1.w.I CuSaM R*hAlIQO
Owner Mailing Address 3 Red Orange Road
Middletown, CT 06457
Owner Property Address 2 9 -7 0 Pe co,,11 c___ v, .
LcL to 1A C? 9 � .
=Owner Telephone No. 8 Cop 3 (4 6 a Ca
Tax Map No: Section I a 8 Block C— Lot ).l
Cross Street E-,j a n c_ky -Df' t �=
Please check each that applies: New Construction ✓
Alteration to Existing System
Residential. V 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. Newn, construction may sub copy of survey with SCHD approval.)
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Signature of Applica14 to
Received by: