HomeMy WebLinkAboutKeeney JUDITH T. TERRY µ Town Hall, 53095 Main Road
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ti k P.O. Box 1179
TOWN CLERK w ,, ,,
REGISTRAR OF VITAL STATISTICS �L , � Southold, New York 11971
.�` Fax (516) 765-1823
MARRIAGE OFFICER �rey �' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1726-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KEENEY, ALICE
Mailing Address 1 46660 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 46660 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3176
Tax Map No. section 75.00 block 3 lot 4.000
Cross Street SOUTH HARBOR ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/24/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •COMA'
Town of SoutholdOHO >�� Application No./ Z9C
Judith T. Terry, Town Clerk t
Town Hall, 53095 Main Road a 2 } $10.00 - Residential
P. O. Box 1179 cryr-11 . $25.00 - Non-Residential
Southold, New York 11971 � �0��'�
Telephone ( 0/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $4,�
DATE 7-.45--- 9/
OWNER NAME: ,799/ e ��ee, y
OWNER MAILING ADDRESS: '/19%i,1J .7(4) .11 rte/ 1 ..0
1,7 /
OWNER PROPERTY ADDRESS: /y7 / / 'o�4'
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OWNER TELEPHONE NUMBER: „..26-'5---" 1/ 2S
TAX MAP NO. : Section 25- Block 3 Lot
CROSS STREET: Fl 49,5177
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential • Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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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 Ap. 'cant
RECEIVED BY:
Town Clerk's Office
DATE: C� j
4
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