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HomeMy WebLinkAboutLeavay Ji1DITH T. TERRY1 ® ` ,� `� ��„ Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS ' ' ` T ttra _ Southold, New York 11971 MARRIAGE OFFICER �' ' .��� Fax (516) 765 1823 1' Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1682-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner LEAVAY, KEVIN AND KATHY Mailing Address 1 265 HIGHWOOD ROAD Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address T BAYBERRY ROAD Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-1817 Tax Map No. section 76.00 block 1 lot 5.000 Cross Street MAIN BAYV I EW ROAD Date Of Last Pump Out 0/00/00 Issue Date: 5/07/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK �cSFOIA,T= /6 �� Town of Southold �� CQ� Application No!_ , Judith T. Terry, Town Clerk , � � � . ' -7-:.,-;t'„? .G 1 $10.00 - Residential Town Hall, 53095 Main Road .� - P. O. Box 1179 cry Vs. ` ~ ' ; $25.00 - Non-Residential Southold, New York 11971 'GI: 1 N.11 �Tephone _ 1 ° 4 0, . (516)le765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ /O. O . DATE 94- ®29- 9f OWNER NAME: /4✓e0 X71S eite614/ LeiL-V OWNER MAILING ADDRESS: ®26, S fir 9h ®a) /ear . S e--a ici Ai.7. I f y7 / OWNER PROPERTY ADDRESS: ,84i./ � 1/ de°' . S c9--u !<d (i1 .71 r OWNER TELEPHONE NUMBER: 76-S-- (1/7 TAX MAP NO. : Section 1 (p Block .{ Lot S CROSS STREET: 7/1-444.1, /% .,,G-Grtf) 41. TYPE OF SYSTEM: Septic Tank ✓ New Existing Cesspool V New Existing e7 Residential Non-Residential • DATE OF PREVIOUS PUMP-OUT: at X/ 0.001". 6-1.4-t- UAC? y1.49 /O — 90 . 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.) i''.--ZI - ar' I/ / -Sig ure of Applirnt RECEIVED BY: G �J - ft me To m 1 rk's Office DATE: APR 3 0 ' 11 Southe d T©w et Cbert = . , ,.. v.. . . v ... - _ v Hwy„3 - G'.N,.-+,. ,v.i-tv ...a. - :,.': %.sY�"e• � f /' 71/- 4 rr4 /' 4112% Cid 1 f � � t l` b1 r C�,M �'� 6 4.1P