HomeMy WebLinkAboutHarris Elgri Town Hall, 53095 Main Road
P.O. Box 1179
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® ;l� Southold, New York 11971
JUDITH T.TERRY r=®l ' Ni��i� FAX(516)765-1823
%zzz ��'`` FAX
(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1376-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HARRIS, JOHN A.
Mailing Address 1 3850 YOUNGS AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3850 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3253
Tax Map No. section 55.00 block 2 lot 15.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 2/01/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • c�IFU(,'�'-
Town of Southold e'0 % Application No. 1,3
Judith T. Terry, Town Clerk
(to .4`44
:�
Town Hall, 53095 Main Road ,,. a $10.00 - Residential
P. O. Box 1179 Z , , � �i � $25.00 - Non-Residential
Southold, New York 11971 O ® ` ?, ���'`,
Telephone .OI `A� ,'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
oor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE
OWNER NAME: .j/1 ///
OWNER MAILING ADDRESS: O 6 O, 1‘5 /9(/E.
\j in/0100 AA 1/f / -
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot /5-
CROSS
SCROSS STREET: `7/
TYPE OF SYSTEM: Septic Tank V- New Existing V
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: A/ V eRi
LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
4,7
Signa ure`of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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