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HomeMy WebLinkAboutHavens { Town Hall, 53095 Main Road � a TOWN CLERK � �� P.O. Box 1179UDITH T. TERRY z9 rTi '' Southold, New York 11971 REGISTRAR OF VITAL STATISTICS �. 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. 1623-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner HAVENS, MARY I. Mailing Address 1 420 MILL CREEK DRIVE Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 420 MILL CREEK DRIVE Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-3098 Tax Map No. section 135.00 block 3 lot 45.000 Cross Street GROVE ROAD Date Of Last Pump Out 0/00/81 Issue Date: 2/20/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK '0FO '-. Town of Southold OHO iC; CQG' Application No. /64.. Judith T. Terry, Town Clerk f ,"r " =� y ''` i $10.00 - Residential Town Hall, 53095 Main Road P. O. Box 1179 ( " . hzi � 0 •�. $25.00 - Non-Residential Southold, New York 11971 TelephoneOj ��O ��' (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. /1, Fee $ 7'© • DATE t7/12YE us 'OWNER NAME: 2: • • OWNER MAILING ADDRESS: 11-cR p � C . _ _ �JGwr cs�V � OWNER- PROPERTY ADDRESS • OWNER TELEPHONE NUMBER: 74`5 `3°? TAX MAP NO. : Section Block, Lot CROSS STREET: 6- V" O U TYPE OF SYSTEM: Septic Tank New Existing 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.) Signature f Applicant RECEIVED BY: /(// Town Clerk's Office DATE: �/i /97 1 ~ / - . :111,7: 1 . . ___.. . ' -- � � - c~ia_^ce= ~' ^ _ - .. ' '_--_ ( _ _ _ - _ - _- _' - - --(`__ ------------ -- -- -- � . __ `' _ . ! .) / 7 r � � / ' ..~ v �^ �.` \ | \ `