HomeMy WebLinkAboutArena SCtlrHCLD V*SrBAATER 11 SPO6AL PERM T
CPEPATI CN PERM T
SEPTI C TANK or CESSPOCL
Cper at i on Per ni t W. 4453-R Resi dent i al X Pbn-Resi dent i al
Fee $ 10. 00 New X Exi st i ng
Name Cf Ower CAM D & SANDRA AFEM
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Mailing Address 1 416 TACCN C ROOD
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Mi I i ng Addr ess 2
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0 t y St Zip GREEMV CH CT 06831-0000
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Pr oper t y Addr ess 1 16015 NEW SLFFCLK XEN E
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Property
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Property Address 2
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(I t y St Zi p NEW SLFFCLK W 11956-0000
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Owner Tel ephone W. 914-420-4334
Tax h&p W. sect i on 117. 00 block 6 1 of 24. 000
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Cr oss St r eet BUNW LANE
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I ssue Dat e: 5/21/ 13 8 i zabet h A Nevi I I e
-------- Sout hol d Tomn CI erk
(TCIAN SEAL)
�o��s11ff0�,�coG
ELIZABETH A. NEVILLE y� Town Hall,53095 Main Road
CD
TOWN CLERK go = P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICERy • �� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �01 '�►aO 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--V-/-Or Non-Residential @$25 Application No.
� S
Permit No. � Z
Owner Name 'hmAld a4id r'sov� A_7_tr�a_
Owner Mailing Address T/('0- 6r GLG Q7C/�-�G1
r to CT D
Owner Property Address /
Owner Telephone No. 91 `T O- e43 3
Tax Map No: ,,//�� Section Block 0C Lot
Cross Street IV[A/ � k 0Ad 8"&Sd An4t_
Please check each that applies: New Construction
Alteration to Existin 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 mit copy of survey with SCHD approval.)
IdA�
Signatur pplicant Date
1
Received by:
i
OPEN AREAHAY STAIR � S I �
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