HomeMy WebLinkAboutDietz Town Hall, 53095 Main Road
P.O. Box 1179
_ s� ��' Southold, New York 11971
JUDITH T.TERRY :__ �zs' �q0- TELEPHONE
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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. 774-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DIETZ, MARY CLINTON
Mailing Address 1 820 SIGSBEE ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 820 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8572
Tax Map No. section 143 . 00 block 1 lot 10. 000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,•
OFFICE OF THE TOWN CLERK ' r
Town of Southold ���� ® �Q ' Application No. 71'71
Judith T. Terry, Town Clerk Affi`j 41.5
Town Hall, 53095 Main Roadoa Residential
P. O. Box 1179 t' ' Non-Residential
Southold, New York 11971 5 ?IzjcTelephone , "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ... 10( 2 5 I 'in'
OWNER NAME: ;Ae,Vs1 C`I.fAbv, u ie. a
OWNER MAILING ADDRESS:.
OWNER PROPERTY ADDRESS: '12_0 r..a
6.-1 )
G 1 c-�OWNER TELEPHONE NUMBER: x'$72
TAX MAP NO. : Section 19. Block ( Lot /0
CROSS STREET: m_r J f2
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ✓ Existing ce V..c.o d ex;('s•(``-w
Residential ,/ Non-Residential -J
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.)
Pyl(440-,K2
ignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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