HomeMy WebLinkAboutDursn, Rita do., ?sof f0(,��0,
ELIZABETH A.NEVILLE t,,��0 \ Town Hall, 53095 Main Road
TOWN CLERK C - P.O. Box 1179
y Z Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS ��, Fax (631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER �1 * #o• Telephone Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER - ,,i��� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4119-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DURAN, RITA
Mailing Address 1 1948 LEXINGTON AVE
Mailing Address 2
City St Zip MOHEGAN LAKE NY 10547-0000
Property Address 1 1145 SMITH DRIVE SOUTH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 9114-528-7702
Tax Map No. section 76.00 block 2 lot 33.000
Cross Street TERRY PLACE
Issue Date: 1/10/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
•
,
OFFICE OF THE TOWN CLERK COFUUr -
TOWN OF SOUTHOLD 0�, COG Application No. f(
LLIZABETHA.NEVILLE,TOWNCLERK $10.00 - Residential
P.O.BOX 1179
Cr3SOUTHOLD,NEWYORK 11971 $25.00 - Non-Residential
Telephone 1 0
(516) 765-1801
TOWN OF SOUTHOLD
• SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee
DATE / • 3/ C /
OWNER NAME:
OWNER MAILING ADDRESS: c94S C
WNER PROPERTY ADDRESS: //1-74
O O
A
OWNER TELEPHONE NUMBER: 9/� �• c.
TAX MAP NO. : Section °/ilO Yom% Block — Lot �3
CROSS STREET: `���`�_
TYPE OF SYSTEM: Septic Tank New 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.)
Signaturs. of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
1 IIIAimam moil p1111V1 _ IIIIIIII0ill III 111II1I0IlIII01111. . ...11111 ._IIII I.1111 1 .., ........II III II II 1111 III 11101111111100 01.MUNI 1IIIIIIIIIII1010010u1101.1 IIIIIIIIIII IIUIUIIII nlulluIIp,I„Ie
11
`J fes,li /,ice s7.
T
r le:1
SI
I
5 _44..4-4,
L /L
II f
S
f„..___,1___t
1 III3` f----HW -----,„„..._
OF i
pi
2
`>N • n e c S f,-f-1 L
te
1,:114.71.A.” A AL
(6
Rita 1)uran
1145 Smith I)rive South
Southold ,