HomeMy WebLinkAboutDemaria (2) I
•ra r Town Hall, 53095 Main Road
O �,!' P.O. Box 1179
-__ 7�`J�p 0° Southold, New York 11971
JUDITH T.TERRY 4W01,1 �'i.°� FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1291-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
-
New Existing X
Name Of Owner DEMARIA, RICHARD
Mailing Address 1 900 MINNEHAHA BOULEVARD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 900 MINNEHAHA BOULEVARD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2904
Tax Map No. section 87.00 block 2 lot 6.000
Cross Street OSSEO AVENUE
Date Of Last Pump Out 0/00/80
Issue Date: 10/31/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'S�FFD(,r�
Town of Southold � � Application
Judith T. Terry, Town Clerk ; ;
Town Hall, 53095 Main Road
$10.00 - Residential
P. O. Box 1179 tr2IA
'% � 1 �
.r,� .,5 � $25.00 - Non-Residential
Southold, New York 11971 0,`4Z!,
Telephone _gi N.aO
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /
f
DATE •
OWNER NAME: ?,/ G Yl A-12p •
OWNER MAILING ADDRESS: ya 7 /� i hem
JDtJlhoA (, -7„ , /CCd ? � -
OWNER PROPERTY ADDRESS: ���
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section y Block a Lot
CROSS STREET: SSF ) Auc
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9'
j
' 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
FW.:
DATE:
0C 31 198j
low clerk South®0t
'OR 31161/1-a2-
crredi?"' `7"- 1 Ct./4,2rte.
/600 ° ect4c1„.
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