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HomeMy WebLinkAboutStuckart, Kathleen `' OFFICE OF THE TOWN CLERK ,QcOHurt," Application No. 110 TOWN OF SOUTHOLD , �. G ELIZABETH A.NEVII.i.F,TOWN CLERK $10.00 - Residential P.O.BOX 1179 cn ,i SOUTHOLD,NEW YORK 11971 �; $25.00 - Non-Residential Telephone *ei0:' (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICAT ION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 4/ 9 Fee $ /tc .C c DATE OWNER NAME: ,1 /i /e•/ 5�i1Ci f OWNER MAILING ADDRESS: / S acv � (.; au.r7t v�Q9 �Q.rior, A/.y . "96,1 OWNER PROPERTY ADDRESS: 5D �` Pie �" • .51/rn-f,/cd it/./ /r 97/ OWNER TELEPHONE NUMBER: (6,3/) 7,,t5--3002-4 TAX MAP NO. : Section ,3-9, oc. Block C Lot 9, 6c)5 CROSS STREET: ac Ai i/seta Ave . TYPE OF SYSTEM: Septic Tank New V Existing Cesspool New Existing Residential Non-Residential 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.) �/2 E $77Jj2, 2L Signature of Applicant RECEIVED BY: Town Clerk's Office DATE: /v/.c e5-Eat-e-4- . .-,t/rt/Y 2F D ,„,ti lk o• 4144 4514'6' �, ✓.!'1C�Wv7', , ► . ` - .'gyp , O \S t tie,. . ' , * ,.OA ; Si ,o ng, ,,y2, _ t�Si Q.E G=� ''' 00 6'.5.4(3 ' v 10 % t. 4)30. tv N N \kg>2 4 k Li 0 V 0 l• V t,0 1.1R.a ..•r PUOMPe a u ea reeluennD , seeurtese'V o1 ,»,niisui pue, /v/,c 49'Ea, -.9,i ,v/,c e)L.r©..p ,e8 Atineluer4 9etl p.m'permed ri uofhd N a I1ue \ *7V Mme"! `\C' kA tallawa PM fn . vie ix p sirgOlo an»/NIP3 I to IOU worn r . . • • L