HomeMy WebLinkAboutDart OFFICE OF THE TOWN CLERK G ic_pFQU(c
Town of Southold Q (fy
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 1
o ; ,
P. 0. Box 1179 i,t tt' - : g .
Southold, New York 11971 0 ®, `O�-�!'
Telephone - ' �'Q( )0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 508 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Alice J. Dart
OWNER MAILING ADDRESS: P.O. Box 363
Southold, New York 11971
OWNER PROPERTY ADDRESS: Bayview Road
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3855
TAX MAP NO. : Section 78 - Block 1 Lot 10.19
CROSS STREET: Grange Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown "
Judith T. T ry
Southold Town Clerk
DATE: December 2, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cSFO(,r =
Town of Southold �� CQG Application No. 5.or
Judith T. Terry, Town Clerk 4.4, 1
Town Hall, 53095 Main Road c Residential
P. O. Box 1179 . ri Non-Residential
Southold, New York 11971 , vrt7
Telephone -
(516) . 765-1801 =01 �,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE No , 26 / J7
OWNER NAME: Ke._ 1
OWNER MAILING ADDRESS: I QA,J d
f
OWNER PROPERTY ADDRESS: S
OWNER TELEPHONE NUMBER:
•
TAX MAP NO. : Section ES7 Block ( Lot /O 1
CROSS STREET: rows( F
,
TYPE OF SYSTEM: Septic Tank _New Existing /0
Cesspool )43
New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: -2
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
` t
Signatue of Applicant
RECEIVED BY:
Town Clerk's Office
RECEIVED
DATE:
Irwin Cliark Southold
1-0 CS-to- n‘
10)(;c4? c-Solciroco e-S,At-d
i� , S ac�'OS
ctssx°I
1
(PO
C