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SCUTHCLD VIASTEVIATER D SPOSAL PERM T
CPERATI CN PERM T
SEPTI C TANG or CESSPOCL
Cper at i on Per ni t W. 4458-R Resi dent i al X Nbn-Resi dent i al
Fee $ 10. 00 New X Exi st i ng
Imine Cf Ower LCRETTA FART A
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NN Iing Address 1 1911 BEDFCRD AVENUE
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Nbi I i ng Address 2
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City
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City St Zip NCRTH BELNCTTE W 11710-0000
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Pr oper t y Addr ess 1 535 SHCF;E OR VE
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Property
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Property Address 2
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City
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City St Zip GREENPCRT W 11944-0000
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OAner Tel ephone W. 631-734-6800
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Tax Ntp W. sect i on 47. 00 block 2 1 of 16. 000
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Cross St r eet SI LVERNERE RiCAD
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I ssue Date: 9/06/ 13 B i zabet h A Nevi I I e
-------- Southol d Tomn d erk
(TClIN SEAL)
F -
SUFF01
ELIZABETH A.NEVILLE Town Hall,53095 Main Road
TOWN CLERK do z P.O.Bog 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER a�' Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER 1 l�t `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 @$10L or Non-Residential @$25 Application No.
Permit No.
Owner Name 'r2- H �I�r��
Owner Mailing Address I9 1 d�Ord AZVn O P
aar4h -aelnonce�q n o I
Owner Property Address_a'S� 5 e �1�✓Q.
Owner Telephone No. � �— �c� P( / r7,-V- (,1)90n
Tax Map No. 1400 Section 0 Block Ok Lot 16
Cross Street 511 rz�=Pre /Zc C/
Please check each that applies: New Construction
Alteration t�_System X
ResidentialNon-Residential
NOTE: LOCATION MAP MUST BE SUBmimD WITH APPLICATION. (Locate
building and systcm; 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.) SQA' o t'42 r
4 00,
Signature of Applicant Date
Received by:
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