HomeMy WebLinkAboutMcCarty SC UrF CLD VIASTEVIATER d SPCGAL PERM T
C PEPATI CTI PERM T
SEPTI C TAN( or CIESSPOCL
Cper at i on Per ni t W. 4454-R Resi dent i al X Nbn-Resi dent i al
Fee $ 10. 00 New X Exi st i ng
Name Cf Ower TFERESA NDCARTY
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lAi I i ng Address 1 24 FI RST AVDLE
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Wi I i ng Address 2
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0 t y St Zi p FAST ROCKAVIAY NY 11518-0000
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Pr oper t y Address 1 330 V'ESLArD RD
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Property
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Property Address 2
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O t y St Zip SCUTHCLD W 11971-0000
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Canner Telephone Nb. 516-721-0108
Tax Nbp W. sect i on 59. 00 block 2 1 of 100
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Cr oss St r eet BI ROH ROOD
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I ssue Date: 6/06/ 13 B i zabet h A Nevi I I e
-------- Southold Tomn a erk
(TCVW SEAL)
o�oSUFFot�.�
ELIZABETH A.NEVILLE o y� Town Hall,53095 Main Road
TOWN CLERK y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O l.1C Southold,New York 11971
MARRIAGE OFFICER �Q 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. Lf
Permit No. L4 Q'Q
Owner Name Y-fie+-e S o,
Owner Mailing Address r `4 i CS4 Ale-
'a4 s�
Owner Property Address O 2S
GcDi .+ kc>14 Liu �
� 1� 7I
Owner Telephone No. (a — I L5
Tax Map No: Section Block _ Lot D D
Cross Street � �— ?::. �
Please check each that applies: New Construction ✓`
Alteration to Existing System
Residential u--' 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.)
gnature of Applicant Dat
Received by: 0_�'