HomeMy WebLinkAboutDunne (2) {
0004
• JUDITH T.TERRY ; ® Town Hall,53095 Main Road
TOWN CLERK @@g P.O.Box 1179
REGISTRAR OF VITAL STATISTICS ‘0 Q 1�1 Southold,New York 11971
/MARRIAGE OFFICER �� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER ®. •�,,I Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,//"//
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3323-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DUNNE, LOIS
Mailing Address 1 2175 PINE NECK ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2175 PINE NECK ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-51193
Tax Map No. section 70.00 block 5 lot 48.000
Cross Street OAKLAWN AVENUE
Issue Date: 4/27/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c.SFUL -
Town of Southold � CQ ',� Application No. 334.)
Judith T. Terry, Town Clerk t.41.\
Town Hall, 53095 Main" Road r4ac $10.00 - Residential c/
P. O. Box 1179 cry •. 1-n ;' $25.00 - Non-Residential
Southold, New York 11971 QL -" •••
�jfi ••
Telephone _�j `��� •
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: [.,0(,,S
OWNER MAILING ADDRESS:, 4/ 76. - 1Y)-2 0 1e_CCC
s" ,f-eu„cd, 1)( ' 1/1g-7 _ _ _
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: �(
...c7(0A
TAX MAP NO. : Section -7 (av Block Lot `
CROSS STREET:
TYPE OF SYSTEM:' Septic Tank New Existing
Cesspool 17 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.)
pe,‘
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: RECEIVED
APR 2 71995
Iowa Clerk Sootl'ktl&
4 ^
TOWN OF SOUTHOLD
.�''',�FFOLf-�'':
Ticket No. 1•
SCAVENGER WASTE REPORT ----ft *�;;�° °�
Name of Hauler..19176M---. )411
Load @<`0 bllons
Permit No. 0 Half Load @ Gallons
Truck Capacity 0 $ Paid
(date)
LOCATION: 0 Split load @ Gallons
(Validation of Payment)
0 New 0 Repeat 1. , �; y
•
Name of Owrur . ,.. ,.c L I.xlJ(
Street .. . :'-.r. A. .
Hamlet
Telephone No. Tax Map No. .`7 `a',= o
Cross Street
DIAGRAM (Locate buildings and cesspool/septic system and approximate distance in feet
between buildings and system; give north arrow.)
/*r...,
ILVAIQJIT
I hereby certify that the above originated within the Town of Southold/Town of Shelter Island
at the above location, and to the best of my knowledge contains no chemicals, hazardous, or
toxic wastes. False statements made herein are punishable as a misdemeanor pursuant to
Section 210-45 of the Penal Law of the State of New York, and may result in my arrest and the
impoundment of the vehicle I am driving.
Name of Driver ,tf‘r\AIV\A---;
Signature of Driver ..
Received by /... ••
Date Time
(1)Trea,ineni ( cmi