HomeMy WebLinkAboutHusing 4,4 a7
Town Hall, 53095 Main Road
C) - ,��� P.O. Box 1179
®� �® � New York 11971
JUDITH T.TERRY - Southold,�� FAX(516)765-1823
�'' TELEPHONE(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. 1390-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HUSINC, MARTHA
Mailing Address 1 P. O. BOX 696
Mailing Address 2 PECONIC BAY BLVD
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1150 OLD MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8571
Tax Map No. section 126.00 block 5 lot 12.000 -
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/21/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
a ...
OFFICE OF THE TOWN CLERK 'S\FFUCA,�'-
Town of Southold C' ation o.
Judith T. Terry, Town Clerk �� �. /3%D
. : ?' ; _. :�
,, t� .0 $10.00 - Residential
Town Hall, 53095 Main Road \
p. 0. Box 1179 Cf' , 0144; i
$25.00 - Non-Residential
-
Southold, New York 11971 mO -7-®_
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ -
DATE ' •"`'-Z 3/9
R
OWNER NAME: �d� (A i/J-/-A//i/ •
•
OWNER MAILING ADDRESS/A—e-0,ii 'Cr A,g1- ,q/U,
OWNER PROPERTY ADD Fc5F .
ki :/frei2 �2 7/7 ) /9Z-
OWNER TELEPHONE NUMBER: 29f- cr3"'7/
TAX MAP NO. : Section -/7. C Block Lot /2- C Pi`
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing_ u --
Cesspool i New Existing L�
Residential I/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: l/ 3 o / -7
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 of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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