HomeMy WebLinkAboutHellman Aco4f(1114.4,10,7-
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JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1123-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HELLMAN, CHERYL
Mailing Address 1 RT 5, UNITY COMMUNITY
Mailing Address 2
City St Zip LANCASTER SC 29720-0000
Property Address 1 4910 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 803-286-9798
Tax Map No. section 79.00 block 2 lot 4.004
Cross Street SHIP'S DRIVE
Date Of Last Pump Out 0/00/83
Issue Date: 5/24/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .0 COW
Town of Southold �O� CQG' Application No. /7,-;
Judith T. Terry; Town Clerk
Town Hall, 53095 Main Road ^ ` : Residential
P. O. Box 1179 v' _ �r T ►' Non-Residential
Southold, New York 11971 O ®: •�`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
CNV 1 7 1969
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: t✓� (
L
OWNER MAILING ADDRESS:
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OWNER PROPERTY ADDRESS: / /1./#1&:--- (--/A°•" ,_-.2�
OWNER TELEPHONE NUMBER: (9-0,6 �eY'`(o L2(1
TAX MAP NO. : Section 2 9 Block 6� Lot 2. 47
CROSS STREET: s,W// De//1E..
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool �✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: )0Q 571f'lc2 1? Y3 "~
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.)
•
Sig':ture of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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