HomeMy WebLinkAboutLeverich JUDITH T. TERRY Z • Town Hall, 53095 Main Road
TOWN CLERK r� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER ‘y '' Fax (516) 765-1823
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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. 3169-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LEVERICH, RUTH K.
Mailing Address 1 BOX 322
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1475 OAKLAWN AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1035 "
Tax Map No. section 70.00 block 3 lot 4.000
Cross Street MAIN ROAD
Issue Date: 2/04/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �\FFD(,�'��"
Town of Southold �- e-% Application No.(3/6?
Judith T. Terry, Town Clerk ham. `
Town Hall, 53095 Main Road ° $10.00 - Residential
P. O. Box 1179 Southold, New York 11971 O '�. $25.00 -
Non-Residential
Telephone 4e1.41- �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
' ; !-P A I CA'. I J N
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE P51V Y
OWNER NAME: qui- / (/
OWNER MAILING ADDRESS: 1 '`�, 0 A IC 1-4
7-13 Ox - -BC
OWNER rrwrctc i Y ADDRESS:
Cet g-r-D4
OWNER TELEPHONE NUMBER: '74 J /
TAX MAP NO. : Section 7J Block -3 Lot
CROSS STREET: )timed- ' 1 OL
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing l�
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 c!oosest road.)
.40
,t1
Signature of pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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