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SCUTHCLD VO TEV1ATER Cl SPOl:,AL PERM T
CPERATI CN PERM T
SEPTI C TALK or CESSPOCL
Oiler at i on Per M t No. 4464-R Resi dent i al X Non-Resi dent i al
Fee $ 10. 00 New Exi st i ng X
Nacre Cf Owner BETTY FERVPM
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W I i ng Addr ess 1 305N BAYVI EVV READ EXT
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Nbi I i ng Addr ess 2
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a t y St Zi p SCJTHCLD NY 11971-0000
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Pr oper t y Addr ess 1 305 N BAYM EVV ROAD EXT
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Pr oper t y Addr ess 2
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CI t St Zi p SCLITHCLD NY 11971-0000
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OAner Tel ephone W. 631-765- 1886
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Tax Nbp W. sect i on 78. 00 block 8 1 of 16. 001
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Or oss St r eet CEDAR DRI VE
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I ssue Date: 4/ 18/ 14 B i zabet h A Nevi I I e
-------- Sout hold Tovai CI erk
(TOIN SEAL)
o�oSUFFot,��oG
ELIZABETH A. NEVILLE �� Town Hall, 53095 Main Road
CD
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER ifJ 0� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �1 �a 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.
Permit No. 6R
Owner Name 7
Owner Mailing Address
Owner Property Address
Owner Telephone No.
Tax Map No: Section j
Block Lot _
Cross Street c: r I--f—1\)�-
Please check each that applies: New Construction
Alteration to Existin ystem
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.)
Ignature of Applicant Date
Received by:
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