HomeMy WebLinkAboutDorman , , 4FOLI�
® coG
Frt
Town Hall, 53095 Main Road
��®r��� P.O. Box 1179
0' Southold, New York 11971
JUDITH T.TERRY `�-.�,T��'�� FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1551-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DORMAN, DOROTHY
Mailing Address 1 193 WALKER STREET
Mailing Address 2 APT. #112
City St Zip LENOX MA 01240-0000
Property Address 1 1800 VILLAGE LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2524
Tax Map No. section 24.00 block 2 lot 22.000
Cross Street FLETCHER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK .c�OFO(k '
Town of Southold � CQG' Application No./45:37
Judith T. Terry, Town Clerk yct
Town Hall, 53095 Main Road 7 $10.00 - Residential
P. O. Box 1179 LS, =r `'° ' ; $25.00 - Non-Residential
Southold, New York 119710-�1`�
Telephone 01 s� /
Sit
(516) 765-1801 .
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Q ,°>
DATE 10 - 6, - 0
OWNER NAME: C.Po Z o r �� /' ri I✓") �
OWNER MAILING ADDRESS: tu�)_ ajKe- �, I� � , ry
OWNER PROPERTY ADDRESS: ) 0 0 a31k e Lane
,ham
.")
OWNER TELEPHONE NUMBER: ( i
TAX MAP NO. : Section Block Lot
CROSS STREET: 6T6) r14--A c4".
TYPE OF SYSTEM: Septic Tank New Existing
/
Cesspool i�' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: k . .I Q• 161 %cf (nit.30 )4( ;�
LOCATION MAP: Must be attached hereto before .er'r\it may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
j.D6-z_cp 174 -)rn • D-z-T111,
Signature of Applicant
RECEIVED BY:
Town ,Clerk's, Office
'BATE: -