HomeMy WebLinkAboutLillis _ . A4 ;`Y ;�' Town Hall, 53095 Main Road
,�® • ,� P.O. Box 1179
__ � ��� Southold, New York 11971
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JUDITH T.TERRY /����
TELEPHFAXONE(516)765-1801
TOWN CLERK
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. 1216-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LILLIS, GARY A.
Mailing Address 1 4710 OLD NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 4710 OLD NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3569
Tax Map No. section 55.00 block 2 lot 8.004
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
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Town of outhold %‘5 Application t� _ �� Application No. fig
Judith T2Terry, Town Clerk . Ad" w
Town Hall, 53095 Main Road ;At .G I $10.00 - Residential
P. O. Box 1179v' rx '� '
� $25.00 - Non-Residential
Southold, New York 11971
ter _,
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Telephone `Zy
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 8"/� Pf
'OWNER NAME: 61.44 /1.- f •
OWNER MAILING ADDRESS: ' '7/0 ee,/Z' /41A7s4( D41)
(c4.4d7A/o,4 -44eb.7D2.� //9 7/
OWNER PROPERTY ADDRESS: '/ 02i>7/o o ' /`�/
4v6'1,✓ /evtrt_ //9 7/
OWNER TELEPHONE NUMBER: ($ ' )
TAX MAP NO. : Section Block 2-- Lot` �` Lf
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing f/
Cesspool New Existing/
Residential p Non-Residential
DATE OF PREVIOUS PUMP-OUT: ' vE(/`
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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