HomeMy WebLinkAboutMcKeon, Kimberly ,.�, S�Ffot,��oG
ELIZABETH A. NEVILLE _ 'ld Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
t.
MARRIAGE OFFICER L Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER `�y�Ql 4;00,, Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER I
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4080-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MCKEON, KIMBERLY
Mailing Address 1 44 GRANT DRIVE
Mailing Address 2
City St Zip VALLEY STREAM NY 11580-0000
Property Address 1 1755 OLD ORCHARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-561-9711
Tax Map No. section 37.00 block 3 lot 12.001
Cross Street
Issue Date: 4/27/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FFO .
TOWNOFSOUTHOLD ��� . ' .•: Application No. 41E1,6
ELIZABETH A.NEVILLE,TOWN CLERK � $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 $25.00 - Non-Residential
Telephone *el i 0:1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION,
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 04 ") l ( I\
Fee $ /° •0 O
DATE 1 23l D
`� 1
OWNER NAME: (44,10ee( � �la�
OWNER MAILING ADDRESS: 444 �(L � braiuc
Uor-Le ` t2e-ft- i A.) ( I / Sfs
OWNER PROPERTY ADDRESS : L9-`5.- - OL k_ O c,k , .k lave.
eco5f V144R-ia)
OWNER TELEPHONE NUMBER: ( 5l6 ) 5'6/-
TAX MAP NO. : Section 3-3- . 00 Block 3 Lot /2 .00/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ✓ Existing ?,tpf*c.ee„
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.)
I '/ 61,
Si. ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: