HomeMy WebLinkAboutO'Leary, Joan ,/� O�, O��-c
S�FFo
ELIZABETH A.NEVILLE ��,j Gy �; Town Hall, 53095 Main Road
TOWN CLERK oP.O. Box 1179
ti Southold New York 11971
REGISTRAR OF VITAL STATISTICS '
�� Fax(631) 765-6145
MARRIAGE OFFICER :\ifi/� `. �1
Telephone (631) 765-1800
RECORDS MANAGEMENT OFFICER "'/ �
Ql # 60'6
FREEDOM OF INFORMATION OFFICER •_ • r�' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4190-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner O'LEARY, JOAN
Mailing Address 1 145 PARKWAY DRIVE
Mailing Address 2
City St Zip WESTBURY NY 11590-0000
Property Address 1 770 OLD SALT ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-333-8394
Tax Map No. section 144.00 block 5 lot 14.000
Cross Street ROCHELL PLACE
22Issue Date: 2/11/03 ° e
thold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �S�FFU(,r`;'
TOWN OF SOUTHOLD \, OG= Application No. L.-/M
ELIZABETH A.NEVILLE,TOWN CLERK
$10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 to $25.00 - Non-Residential
Telephone 'Rl 01
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: •J 00,y) � LPA ,/
OWNER MAILING ADDRESS: /f s- part(c.a.)
(,)e54 bw-y 4/ i i I°
OWNER PROPERTY ADDRESS: 770 Old 50„14- Re
a,(-I- {-cpc IC NV , t 9 f-2-.
OWNER TELEPHONE NUMBER: „VA gj'1
TAX MAP NO. : Section PH, a o Block S� Lot / `74. 060
CROSS STREET: Roche(( Pla.ee
TYPE OF SYSTEM: Septic Tank )7 New Existing k
Cesspool X New Existing ->
Residential X Non-Residential
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.)
,(9'e4-
Signature of plicant
RECEIVED BY:
Town Clerk's Office
DATE: