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HomeMy WebLinkAboutKelsey ,Iogi b VFFO(�ee `JUDITH T.TERRY `��o0t �` Town Hall, 53095 Main Road TOWN CLERK ` y Z , P.O. Box 1179 - T ,1 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS : O Fax MARRIAGE OFFICER L 4 •1� Fax(516) 765-1823 RECORDS MANAGEMENT OFFICER c ®•� �A> �� Telephone(516) 765-1800 FREEDOM OF INFORMATION OFFICER ��,,,.�• �� i OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3469-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner KELSEY, AUGUSTUS & BARBARA Mailing Address 1 P. O. BOX 405 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 3790 PECONIC BAY BLVD. Property Address 2 City St Zip LAUREL NY 11948-0000 Owner Telephone No. 516-298-9637 Tax Map No. section 128.00 block 6 lot 4.000 Cross Street DELMAR DRIVE Issue Date: 5/16/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) • ., „., OFFICE OF THE TOWN CLERK COMA' Town 'o'f Southold �� CQG=� Application No. (5 9. Judith T. Terry, Town Clerk .` �1 Town Hall, 53095 Main Road I $10.00 - Residential P. O. Box 1179 cry : ;' $25.00 — Non-Residential Southold, New York 11971roe Telephone Telephone -a- (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL MQY ;13 1996 Operation Permit No. T°I`yn C/etk Fee $ /0: oo !t/10kd DATE -5-// /& OWNER NAME: /4U6.0S %US' a WEZ_ sE'Y _( i-3m?g1)/t/ S -k/ LSF j 7 os7res- OWNER MAILING ADDRESS: BC X cl© /n4 7i Svc IC tiJ /17.5- OWNER 17SOWNER PROPERTY ADDRESS: 7 ?O 2 ' SL LV L Aut?GL_ 71/r OWNER TELEPHONE NUMBER: C570 ? 9g- n.37 TAX MAP NO. : Section /.2 8 Block 6 Lot , , CROSS STREET: - J7Ct ma J2 P- y•r TYPE OF SYSTEM: Septic Tank 1 , - New Existing I j Cesspool ✓ New Existing ✓ Residential ✓ 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.) / 1 Signature of Applican rru RECEIVED BY: n, _ Tow ,Clerk' Office DATE: , 1,3 .'. .l . . 2 / jr ?c PEdoN'c BAY d` i/D 3790 N 64.1 CS s PooL 4l Py` ca25 a Ind M Roos r 1-11 (00-r eroe---AL E� 0