HomeMy WebLinkAboutKneuer ""p
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164 41;.41
Town Hall, 53095 Main Road
P.O. Box 1179
_ 41 °a ��' Southold, New York 11971
JUDITH T.TERRY
�. TELEPHONE
TOWN CLERK (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. 677-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner KNEUER, RITA & VALENTINE
Mailing Address 1 170-95 MAIN STREET
P.O. Box 92
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 170-95 MAIN STREET
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6449
Tax Map No. section 117. 00 block 8 lot 9 . 000
Cross Street SECOND STREET
Date Of Last Pump Out 3/22/82
Issue Date: 4/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •c0F14�'�- 7
Town of Southold �® �0 Application No.
j0
Judith T. Terry, Town Clerk r �`"p
Town Hall, 53095 Main Road ° Residential
p. O. Box 1179 cn ticVz �, . 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 $ /0• . 0 0 -
DATE - 2. ( - E-
OWNER NAME: � I�f1 `4- V4 / - f74/c /A/ u
OWNER MAILING ADDRESS: / 7 i3 - q-_5" J°i(1>it/ s7— g Q1
/YE- of SI, F/ y / 5_6
OWNER PROPERTY ADDRESS: / 7 v -- j 5- ///m l
1/t/ J v r F 0 L 1< /✓ci / / ? 576
OWNER TELEPHONE NUMBER: .6--/ G - 7. 5L — 6 s4 9
TAX MAP NO. : Section /1 % Block g. Lot
CROSS STREET: S el C.,0 b S / •
TYPE OF SYSTEM: Septic Tank New Existing
/
Cesspool 1/ New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3 - a c- c
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.)
feZL— /
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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