HomeMy WebLinkAboutKeogh (3) 11,000 T
,�• Town Hall, 53095 Main Road
tzi;x=ems® �. P.O. Box 1179
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. 1215-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KEOGH, RICHARD
Mailing Address 1 MAIN ROAD, BOX 146
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 MAIN ROD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3544
Tax Map No. section 18.00 block 3 lot 14.000
Cross Street EDWARDS LANE
Date Of Last Pump Out 0/00/86
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�V�FO(,� - /
Town of Southold �� COG Application No. / ii
Judith T. Terry, Town Clerk . 4,443M„ $10.00 - Residential
;i :
Town Hall, 53095 Main Road 4
P. O. Box 1179 -��;, fi , $25.00 - Non-Residential
Southold, New York 11971 O ® �J
Telephone Q( , I‘�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE V)i)
OWNER NAME: 1?-_1 C_)-')
OWNER MAILING ADDRESS: Mgj R047),, 33X j L
Dizt -c, Nky. 119' 57
OWNER PROPERTY ADDRESS: ftt-j NI Qo Ap
OSAF_MT . /ply. jt 9 S®7
OWNER TELEPHONE NUMBER: (5/9 ) 32-3 - 35 /
TAX MAP NO. : Section / Y Block 3 Lot 1
CROSS STREET: O1 j4 s L �
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool K New Existing x
Residential K Non-Residential
DATE OF PREVIOUS PUMP-OUT: %5' 'ft,
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 ppli nt
RECEIVED BY: VV
Town Clerk's Office
DATE: 931 (r7
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