HomeMy WebLinkAboutEller 1,III'®\oy`�FfoL� e
JUDITH T.TERRY 1�� y�c Town Hall, 53095 Main Road
TOWN CLERK N _ P.O. Box 1179
v. $ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 1.
MARRIAGE OFFICER ��4t1, At. Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER 0/ �►a�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. 3396-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ELLER, VIOLA M.
Mailing Address 1 115 SOUTH STREET
Mailing Address 2
City St Zip MANORVILLE NY 11949-0000
Property Address 1 4210 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-878-8240
Tax Map No. section 122.00 block 4 lot 28.000
Cross Street NEW SUFFOLK AVENUE
Issue Date: 10/20/95 _ Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I' '.
OFFJCF-Q•F THE TOWN CLERK I� I
UFFD
Tdwn of Southold , �o� �QG.� Application Nu-.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 11791 ;) $25.00 - Non-Residential
•
Southold, New York 11971 O T��`
Telephone 1 Jilt y►��,
(5,16) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. V
Fee $
DATE
OWNER NAME: (/f JA fi ELL C1`?
OWNER MAILING ADDRESS: // . 30 oT/—i g7-
/194/Yo 7 fir LLE?; //9th'
OWNER PROPERTY ADDRESS: 41A / ® C L e LA/L.&
r1. -TrJ
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section4c9 Block /g Lot
CROSS STREET: rt,_, p) J ��
TYPE OF ,SYSTEM: ''Septic Tank ' ' ' New Existing
Cesspool X 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.)
ViA3r-PC:sci�
gnature of Applicant
RECEIVED BY:
Town C erl/ k's Office ' NA
DATE:, A /C0/: � - -
Aro-vA,
lihzt- -
136c-k- Pa);-Pro
ectid—