HomeMy WebLinkAboutMontgomery SCIJTHCLD VIASTEVIATER Cl SPCGAL PERVI T
CPERATI CN PERM T
SEPTI C TANG or CESSPOCL
C,per at i on Per M t W. 4468-R Resi dent i al X Nbn-Resi dent i al
Fee $ 10. 00 New X Exi st i ng
%ne Cf Owner KEM N & KATHLEEN M]VTG3E.RY
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Mbi I i ng Address 1 870 SM TH DRI VE NCM
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Mai I i ng Address 2
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O t y St Zi p SCLJTHCLD NY 11971-0000
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Pr oper t y Addr ess 1 870 SM TH DRI VE NCRTH
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Pr oper t y Addr ess 2
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O t y St Zip SCLITHCLD NY 11971-0000
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OAner Telephone Nb. 631-765- 1955
Tax Nbp Nb. sect i on 76. 00 block 2 1 of 13. 000
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Or oss St r eet TERRY PLACE
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I ssue Date: 5/06/ 14 B i zabet h A Nevi I I e
-------- Southold Town a erk
(TOIN SEAL)
� ��c�uFFO(�►c
ELIZABETH A. NEVILLE o y� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS O Southold, New York 11971
MARRIAGE OFFICER 'yifJ • ��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �l �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 or Non-Residential @ $25 Application No. 9
Permit No. Z ds
Owner Name
Owner Mailing Address
Owner Property Address shijn
Owner Telephone No.
Tax Map No: Section Block Lot 13-
Cross Street �—✓�� ��-�
Please check each that applies: New Construction
Alteration to Existing System 61"
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.)
Signature of Appli t Date
Received by: