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1 A.1+iSYIL,L Z �` Town Hall,53095 Main Road
C� P.O.Box 1179
RRt3 OF VITAL 8TATISTICS Southold,New York 11971
MARMAGR OFFICER Fax(831) 765-6145
RRDMM MMAG ZNMNT OFFICER Telephone(631) 765-1800
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FREROF DMRMATION OFFICER southoldtown.northfork.net
OFFICE OF TIE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4379-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner CALLIS, J. J.
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Mailing Address 1 PO BOX 537
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 2350 PARADISE POINT ROAD
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-765-2259
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Tax Map No. section 81.00 block 3 lot 1.930
Cross Street ROBINSON ROAD
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Issue Date 9/23/08 Elizabeth A. Neville
------ Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A. NEVILLE o Town Hall, 53095 Main Road
TOWN CLERK ti Z P.O. Box 1179
REGISTRAR,OF VITAL STATISTICSO � Southold, New York 11971
MARRIAGE OFFICER y�0 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.42M.
Permit No. 'C
i
Owner Name
Owner Mailing Address
Owner Property Address 2 3-5�
Owner Telephone No. z Z' J `1
Tax Map No: Section Block 'sJ' Lot
Cross Street /'VA CA e-
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.)
0
Si f Applicant Date
Received by: a e