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ELJZAAMM A.NWILL11,RMC,CMC Town Hall, 53095 Main Road
TOWNCLIM P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11871
M ARRIAGE OFFICEiR, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ,� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER , southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4385-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner JOHN KEITT
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Mailing Address 1 320 EAST 57TH STREET
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Mailing Address 2 APT 15E
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City St Zip NEW YORK NY 10022-0000
Property Address 1 280 BASIN ROAD
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Property Address 2
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City St Zip SOUTHOLD NY 10022-0000
Owner Telephone No. 212-759-9795
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Tax Map No. section 81.00 block 1 lot 1.090
Cross Street OLD PARADIS PT ROAD
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Issue Date: 12/08/08 Elizabeth A. Neville
------ Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE y� Town Hall, 53095 Main Road
TOWN CLERK WP.O.Box 1179
REGISTRAR OF VITAL STATISTICS O .F Southold, New York 11971
Fax(631) 76b-614b
MARRIAGE OFFICER yifJO aQ`'
RECORDS MANAGEMENT OFFICER 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. 5
Permit No. 3588 R
Owner Name — cn rV Q Kr= tT
Owner Mailing Address A An E A S-1 t0 T N S T. 4a PT 15 E
to E\= � U 0Q,K iV U xooaa
Owner Property Address ai�0 E±)As I ) 'RO fid
SO0-TAAL-1�::) NU► \
Owner Telephone No. c2 •1f:e
Tax Map No: Section Block 1 Lot 1 .q Qp
Cross Street (--)Lo P Af ^r'_J\5 F 9-y ' 9_0
Please check each that applies: New Construction
Alteration to Existing System L�_
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.)
o�
Applicant Date
Received by:
COASTLINE CESSPOOL & DRAIN SERVICE
4225 Bridge Lane
Cutchogue, L.Y.,N.Y. 11935
/ICY G.9� .SE,��< �.✓.E f�d�.+�vd l..sfr
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SCCA Lic. #168-LW NYS DEC#iA-600