HomeMy WebLinkAboutHale (2) Yel$"%lf EV(6-4z,,
JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK c ) P.O. Box 1179
REGISTRAR OF VITAL STATISTICS I $ Southold, New York 11971
MARRIAGE OFFICER �® , Fax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3066-R• Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HALE, RODE M. AND PHYLLIS E.
Mailing Address 1 P. O. BOX 231
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 2510 EDWARDS LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3623
Tax Map No. section 18.00 block 3 lot 6.010
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 7/21/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK
Town of Southold X,. C'
Judith T. Terry, �GA. .;
Application No.
y Town "Clerk' ' �
_ .:�. -
Town Hall, 53095 Main Road ,.�`s,� $10.00 - Residential
P. O. Box 1179 tr3 M‘ sr`;,•:y5y
•� • $25.00 — Non-Residential
Southold, New York 11,971: - _ O ® +`:O�',••1`
Telephone 01
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $
DATE D 13! I F13
OWNER NAME: �4'6-LZ fr! -1, uG-.1 tiJG I�
OWNER MAILING ADDRESS: 2-5-1 a L O Lnr 770 5 4i• (
at.e2,, r qs 7
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: /7 -3�3 -3 4
y 7 -fr9 <� 3
TAX MAP NO. : Section Block Lot (
CROSS STREET: •`�� -
• TYPE OF SYSTEM: Septic Tank New Existing D4,
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
-A 't c i/`c c e r ecc1,
c J e-ca <72) 6:-.1!)c-0 s I. rJ v -s- '
�. �ev�T620 71"z1---4--- Signature of Applicant
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RECEIVED BY:
, , - • Town Clerk's Office
DATE:. - _
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