HomeMy WebLinkAboutKelly (2) •
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0 �` Town Hall, 53095 Main Road
0 P.O. Box 1179
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to', to'$ Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1547-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KELLY, WILLIAM B. AND BARBARA
Mailing Address 1 BAY AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 BAY AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6079
Tax Map No. section 104.00 block 4 lot 28.000
Cross Street BROADWATERS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•Y• I III
OFFICE OF THE TOWN CLERK ' FFo((� '-
Town of Southold A1-31".„. CQG', Application No. /.5- 7Judith T. Terry, Town Clerk v $10.00 - Residential - c
Town Hall, 53095 Main Road _ ''` }`;_
p. O. Box 1179 ' ' �' _` ` $25.00 - Non-Residential
Southold, New York 11971 P,4:474
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Telephone - '�
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ° -°� 0
nn 131)-ROWNER NAME: t.0 i /9 ! E12 •
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OWNER MAILING ADDRESS: i+9
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OWNER PROPER-TY-AD-DRESS:- __. (LS/1-4:1 E
OWNER TELEPHONE NUMBER: 670 7314-- acp-if
TAX MAP NO. : Section /U Block 4 Lot 101-0
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
ii
Cesspool_ New Existing �C
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.)
AuLezeno, ,Pil.f -Pe
Signature of Applica t
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RECEIVED BY: 4" ' _ Q.
Town (/Clerk's Office
•
DATE:
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