HomeMy WebLinkAboutDougherty SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4447-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner WILLIAM DOUGHERTY
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Mailing Address 1 6810 SOUNDVIEW AVE
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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 6810 SOUNDVIEW AVE
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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. 631-702-3912
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Tax Map No. section 59.00 block 8 lot 6.003
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Cross Street KENNYS ROAD
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Issue Date: 12/03/12 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
o��SUFfO(,�cOG
ELIZABETH A. NEVILLE y� Town Hall, 53095 Main Road
TOWN CLERK y = P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER y�• 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. 4 4 7
Permit No. 3 2 b
Owner Name W 1 1 . vvt + y.
Owner Mailing Address lo Q 4y (_k v, Q h! V e .
S o d
Owner Property Address S q ✓y\k
Owner Telephone No. 3 ) -:+ 0 Z 3 cl 1 Z
Tax Map No: Section 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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iI Izit � Z
Signature of Applicant Date
Received by: