HomeMy WebLinkAboutDennehy ,� $ Town Hall, 53095 Main Road
"40 � �_ P.O. Box 1179
__ /®1 alt ����.0 Southold, New York 11971
JUDITH T.TERRY iir,� 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. 791-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner DENNEHY, GERALD
Mailing Address 1 BOX 2003
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 1245 OLD FARM ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-298-8981
Tax Map No. section 26. 00 block 4 lot 2. 000
Cross Street KING STREET
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c� FFU(,�
C
Town of Southold �% ApplicationNo. 79
Judith T. Terry, Town Clerk fJ
ResidentialTown Hall, 53095Main Road ti
P. 0. Box 1179 , Non-Residential
Southold, New York 11971 O�®_ *
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O
DATE tQo . /Ffep
OWNER NAME:
OWNER MAILING ADDRESS: eak 2c3
5f '7 /y' ,/9c7
OWNER PROPERTY ADDRESS: /� %' OLD / 4&,41 /cT,9.Y>
U,'i&rv'7 41 '
OWNER TELEPHONE NUMBER: 0276P—
TAX MAP NO. : Section -2b' Block Lot //
CROSS STREET: /4/g
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ?( New X Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: �✓ /�
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: 0_,/,1_ 0(_�
Town C'lerk's 0 fice
R a: -i, -
DATE: - -
AUG 17199 -