HomeMy WebLinkAboutKelley ted'- T;11U -�
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JUDITH T. TERRY
Town Hall, 53095 Main Road
TOWN CLERK u ti P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS �` Southold, New York 11971
�v Fax (516) 765-1823
MARRIAGE OFFICER ® .�
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. 1989-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KELLEY, ROBERT F.
Mailing Address 1 P. O. BOX 1535
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 750 BLUE MARLIN DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4626
Tax Map No. section 57.00 block 1 lot 29.000
Cross Street DOLPHIN DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Fe(,(� a �'Town of Southold 0e51,A_ CQ -` Application No.✓
Judith T. Terry, Town Clerk � ` $10.00 - Residential
Town Hall, 53095 Main Road
p. O. Box 1179 u' �f' ;� i ; $25.00 - Non-Residential
Southold, New York 11971 •
O�O,?:
Telephone : 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT • ?
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /I)
DATE fib// 6/9 -.
OWNER NAME: a�e�\S"' �_ ( er
OWNER MAILING ADDRESS: '( .o , 1 J 3.
o 1‘1• _ ( 1171 .
OWNER PROPERTY ADDRESS: 30 p I tl,e L Y l c �. Dir.ve
5ou.kW N .
OWNER TELEPHONE NUMBER: 57 6 76 S - L h p 3
TAX MAP NO. : Section 1, 000 Block 5 " I Lot ,R4I
CROSS STREET: .iti:•l,
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.)
ILdt-
Signature of A scant
RECEIVED BY:
l/e ,,� �
T� rk's fice
DATE: /7;16,7F Z—
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