HomeMy WebLinkAboutKing ':4fAtt
_�' m s` Town Hall, 53095 Main Road
u.c®' 7` ��`` P.O. Box 1179
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Southold,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. 1150-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KING, FRANCES C.
Mailing Address 1 CEDAR BIRCH ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 CEDAR BIRCH ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2583
Tax Map No. section 15.00 block 9 lot 26.004
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 6/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK TVFFetir t
Town of Southold �� CQ Application No. 1\
Judith T. Terry, Town Clerk ' � ' i►
y ..c 1 Residential
Town Hall, 53095 Main Road
P. O. Box 1179 �' `` •` Non-Residential
Southold, New York 11971 O ®TrR •
Telephone _ .l414l
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE �� C
OWNER NAME: CA
OWNER MAILING ADDRESS: { -- - C:; c
OWNER PROPERTY ADDRESS: r, 0•7- .)
C � 7L , / A V), /I9t
VO4f ' TELEPHONE NUMBER: • 51 e 3 �.,� �� �, o ILA-%
• TAX MAP NO. : Section lb Block 9 Lot , q
CROSS STREET:
C:51-4-1:0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: \n �.ati-`
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.)
Le.,1; 6),c2/(ci,/ k.
-
Z4/%:_49q PM .
Signature of Applicant
RECEIVED BY: p
laov'"�rnlerk's Office
DATE: JUS 13 ��ci
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