HomeMy WebLinkAboutDemos Town Hall, 53095 Main Road
%riP ��� P.O. Box 1179
41 1% 00. Southold, New York 11971
JUDITH T.TERRY :� �� TELEPHONE
TOWN CLERK (516)765-1801
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. 800-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEMOS, TRACY C.
Mailing Address 1 10-04 149TH STREET
Mailing Address 2
City St Zip WHITESTONE NY 11357-0000
Property Address 1 490 NORTH SEA DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1569
Tax Map No. section 54.00 block 5 lot 17. 000
Cross Street KENNEYS ROAD/HORTONS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 8/26/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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A
OFFICE OF THE TOWN CLERK CJS FDC'
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Town of Southold � � �, Application No. �06
Judith T. Terry, Town Clerk . r' `?° . y
Town Hall, 53095 Main Road •. t :4. Residential
P. O. Box 1179 cn �a 'W� i ; Non-Residential
Southold, New York 11971 ��
Telephone ,( -"e"
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee VC
DATE - t� F ,1,9r).•
OWNER NAME: /R/6) ,k/ � Merl oS
Del
OWNER MAILING ADD ESS: /0 r OK /1! �/ �
(1,e)4 ,& 7436-7
OWNER PROPERTY ADDRESS: 1170 cS A- ,l•�
SHOO cn /cle - /i77/
OWNER TELEPHONE NUMBER: /7‘,5- /5-6 7 {
TAX MAP NO. : Section Lc q Block Lot / 7
CROSS STREET: kP,c.),k1-ex g of ¢ /LAD 2 C'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /\J , �cli�r
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.)
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Siena ure of Applicant
RECEIVED BY:
Town Clerk's Office
RECE
DATE:
AUG 2 619
Town Cte Softie