HomeMy WebLinkAboutDavey SCUTHCL D VIPSTEVIATER DI SPOSAL PERM T
CPERATI CN PERM T
SEPTI C TANK or CESSPOCL
Cper at i on Per rri t W. 4472-R Pesi dent i al X Non-Resi dent i al
Fee $ 10. 00 Naw X Exi st i ng
Name a Owner PAI DAVEY
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Nbiling Address 1 1145 BAY HAVEN LANE
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Mai I i ng Addr ess 2
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O t y St Zi p SCUTHCLD W 11971-0000
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Pr oper t y Address 1 920 MSS LANE NCRTH
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Pr oper t y Addr ess 2
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a t y St Zi p CIEENPCRf NY 11944-0000
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Owner Tel ephone W. 631-765-5555
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Tax Map W. sect i on 33. 00 block 2 1 of 42. 000
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Gross St r eet INLET PCND ROOD
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I ssue Date: 9/ 15/ 14 B i zabet h A Nevi I I e
-------- Sout hol d Tom a erk
(TOIN SEAL)
�o�osuFFo�,��oG
ELIZABETH A. NEVILLEo y� Town Hall, 53095 Main Road
TOWN CLERK h Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICSO Southold, New York 11971
RECORDS MANAGEMENT OFFICER RIAGE OFFICERy��• �aO�� TelephoneFax(631) 765-6145
J (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 @ $10X or Non-Residential @ $25 Application No. T J�L_
Permit No. _��
Owner Name �o� C ��U�.1.(
Owner Mailing Address
Owner Property Address 0 CO/W,f9 A)-Z /004"'
� AJ y
Owner Telephone No. 31- '] 1_0 S�
Tax Map No: 10 O b Section _Block Lot _
Cross Street r, k-e—, QtM 4 1Z Z
Please check each that applies: New Construction
Alteration to Existing 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 submit c y of survey with SCHD approval.)
�� / y
S ure o p li Date
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