HomeMy WebLinkAboutKelly OFFICE OF THE TOWN CLERK
- Town of Southold
Judith T. Terry, Town Clerk
Town Hall, - 53095 Main Road
,P. O. Box 1179 `l 6"
Southold, New York 11971 Qui ,, �- e�,
Telephone ®.(
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 410 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: William Brian Kelly
OWNER MAILING ADDRESS: P.O. Box 464
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Southold, New York 11971
OWNER PROPERTY ADDRESS: Founders Path
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3012
TAX MAP NO. : Section 64 Block 2 Lot 33
CROSS STREET: L'Hommedieu
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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Southold Town Clerk
DATE: August 21, 1987
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1(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C1\41:FO(ir •'•
Town of Southold �� y u• CQ '_ Application No. "2]1/47
Judith T. Terry, Town Clerk 's
Residential C----""
Town Hall, 53095 Main Road c -
P. 0. Box 1179 Non-Residential
Southold, New York 11971
Telephone : ., ,,.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ()6 /7 iez7
OWNER NAME: 1, 1 C '1��\ k 'ELL
OWN
MAILING ADDRESS: „___\20=O' a
OWNER PROPERTY ADDRESS: FC)(SAD ?.S 'fa A
C) O L L
OWNER TELEPHONE NUMBER: 7 7K' 3c 0 1
TAX MAP NO. : Section -6 1 Block Lot L'3
CROSS STREET: P 0 (v� N\ TS
TYPE OF SYSTEM: Septic Tank New Existing V-
Cesspool New Existing
Residential V 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.)
Signature of Applicant
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RECEIVED BY• ,�. �� ,, ,, _ I
o` n Clerk'r Offi
DATE: AUG 21 1987
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